Observation and patient disposition after modified-release paracetamol poisoning

Patients do not need to be admitted to hospital if they fulfil the following criteria:

  • they ingested less than 10 g (or 200 mg/kg in patients under 50 kg) of modified-release paracetamol
  • two serum paracetamol concentrations taken 4 hours apart are below the treatment nomogram line, and the second measurement is lower than the first.

Advise them to return to hospital if they develop symptoms of acute liver injury such as abdominal pain, nausea or vomiting.

All patients with deliberate self-poisoning require psychiatric assessment before discharge. To facilitate psychiatric assessment and treatment, if indicated, patients may require a longer period of observation.

Admit patients who are treated with acetylcysteine to hospital.

Patients who have been treated with acetylcysteine can be discharged when the:

  • serum ALT concentration is lower than 50 U/L, or falling if the baseline concentration was higher than 50 U/L1
  • serum paracetamol concentration is lower than 10 mg/L (66 micromol/L).

If the patient is being treated with extended therapy, stop acetylcysteine therapy and discharge when the:

  • serum ALT concentration is decreasing
  • INR is lower than 2.0
  • serum paracetamol concentration is lower than 10 mg/L (66 micromol/L)
  • patient is clinically well.
1 Patients with significant acute liver injury have a high or rapidly rising serum ALT concentration. Small fluctuations in ALT (eg 20 U/L or 10%) are common and do not on their own indicate the need for ongoing acetylcysteine therapy.Return