Acetaminophen Toxicity Clinical Presentation

  • Author: Susan E Farrell, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Feb 6, 2012
 

History and Physical Examination

The clinical course of acetaminophen (APAP) toxicity generally is divided into 4 phases. Physical examination findings may vary, depending on the phase of toxicity.

Clinical evidence of end-organ toxicity is often delayed 24-48 hours after an acute ingestion.

Because antidotal therapy is most effective when initiated within 8 hours after an ingestion, it is important to obtain an accurate history of the time(s) of ingestion, the quantity, and the formulation of APAP ingested. In addition, the history should include any co-ingestants, which may delay APAP absorption (eg, anticholinergic drugs or opioids).

The serum APAP concentration is the basis for diagnosis and treatment, even in the absence of symptoms. After a single ingestion, N -acetylcysteine (NAC) therapy is guided by the serum APAP concentration.

Phase 1 (0-24 h)

Patients may be asymptomatic or report anorexia, nausea or vomiting, and malaise. Physical examination may reveal pallor and diaphoresis. A subclinical rise in serum transaminase levels begins approximately 12 hours after an acute ingestion.

Phase 2 (18-72 h)

Patients generally develop right upper quadrant abdominal pain, anorexia, nausea, and vomiting. Right upper quadrant tenderness, tachycardia, and hypotension may be present. There is a continued rise in serum transaminase levels.

Phase 3 (72-96 h)

Patients may have continued nausea and vomiting, abdominal pain, and a tender hepatic edge. Hepatic necrosis and dysfunction are associated with jaundice, coagulopathy, hypoglycemia, and hepatic encephalopathy. Acute renal failure develops in some critically ill patients. Death from multiorgan failure may occur.

Phase 4 (4 d to 3 wk)

Patients who survive critically illness in Phase 3 have complete resolution of symptoms and complete resolution of organ failure.

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Contributor Information and Disclosures
Author

Susan E Farrell, MD  Assistant Professor of Medicine, Harvard Medical School; Education Consultant, Office for Graduate Medical Education, Partners HealthCare Systems; Attending Physician, Department of Emergency Medicine, Brigham and Women's Hospital

Susan E Farrell, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Michael J Burns, MD Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

References

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