2025 – PAGE 205 – EMERGENCY MEDICINE & TOXICOLOGY
ACETAMINOPHEN INGESTION
In cases of acetaminophen ingestion, obtain an acetaminophen level at 4 hours post-ingestion and plot on the nomogram. Treat with N-acetylcysteine (NAC). NAC can be given by IV or PO. It acts as a glutathione precursor. If the number of tablets is known and the dose exceeds 150 mg/kg (children > 6 years old) or 200mg/kg (children aged 1-6 years old), treat with NAC immediately. Otherwise, you may WAIT until the level returns to plot it on the nomogram before giving the NAC, but it must be given within 8 hours of ingestion. So, if the level will not come back until after 8 hours post-ingestion, give NAC now.
IMAGE: (NOMOGRAM) www.pbrlinks.com/ACETAMINOPHEN1
PEARL: Do not base treatment on liver function testing because they may not be abnormal until three days post-ingestion. Charcoal may be given immediately if the ingestion occurred within 60 minutes of presentation.
SHORTCUTS: Using the 4-hour Rumack-Matthew Nomogram, acetaminophen levels > 150–200 means some liver damage, > 300 means severe damage.
MNEMONIC: Peg for 14 = Chocolate Heart for Valentine’s Day. Peg for 4 = Car with 4 doors. Imagine a troubled 14-year-old boy who has a broken heart on VALENTINE’S DAY because he was rejected by the girl he asked out. To fix his aching heart, he makes a big WHITE CHOCOLATE HEART in which the main ingredient is white ACETAMINOPHEN powder instead of sugar (because he’s a horrible chef… let’s hope someone finds him soon!). He then goes to the CAR which holds his many fond memories and eats the entire WHITE CHOCOLATE HEART over FOUR hours. (WHITE CHOCOLATE HEART = 14 ~ 140 mg/kg. CAR = Nomogram at 4 hours post-ingestion.)
ALCOHOL (ETHANOL)
Alcohol (ethanol) may cause ataxia, nystagmus, perspiration, flushing, hypokalemia, HYPOGLYCEMIA, nausea, and vomiting. Higher intake results in stupor and possibly a coma which can cause a respiratory acidosis (much more common than a metabolic acidosis in the setting of binge drinking). Binge drinking in teens is an INDICATOR OF DEPRESSION, but it is NOT a risk factor for future alcoholism. Treat the patient’s hypoglycemia and hypokalemia. Chronic abusers may have withdrawal symptoms of tremulousness, tachycardia, HTN, hallucinations, confusion, and even seizures.
PEARLS: Alcohol is the most common substance of abuse among adolescents now. It is no longer tobacco. Marijuana is the most common ILLICIT substance of abuse in adolescents. Hypoglycemia can result due to inhibition of gluconeogenesis by ethanol.
PEARLS: Alcohol use can cause mixed acid-base disturbances. A respiratory acidosis from respiratory depression is very common. A metabolic alkalosis can also develop from vomiting and dehydration. Additionally, an anion gap metabolic acidosis can result in those with alcoholism or prolonged use due to the formation of lactic acidosis and ketoacidosis (from the lack of gluconeogenesis and from starvation).
METHANOL INGESTION
Methanol toxicity can result from ingestion of Windshield washer fluid. Patients present with visual complaints (snowstorm appearance), abdominal pain, and a POSITIVE ANION GAP. Treatment is the same as ethylene glycol.
MNEMONICS: “M ~ W.” Also, imagine how terrible your driving VISIBILITY would be in a SNOWSTORM if someone drank all of the WINDSHIELD washer fluid from your car!