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Emergency / Toxicology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Took 40 tablets of paracetamol 500 mg (20 g) 5 h ago; 60 kg; nausea only; 4-hour level pending
Red flags Encephalopathy INR rising pH <7.30 Hypoglycaemia Oliguria Differential diagnosis Other hepatotoxins (mushrooms, herbal, alcohol) Viral hepatitis Ischaemic hepatitis Co-ingestants When to admit, call ICU or discharge Admit: Level above the line, staggered/late/unknown time, abnormal LFT/INR, or any high-risk ingestionICU: Acute liver failure, encephalopathy, acidosisTransplant: King's College criteria metKey points NAC is almost 100% protective if started within 8 h. The four-hour level is meaningless before 4 h. Paracetamol is the commonest drug overdose worldwide — combination cold/pain products hide extra paracetamol. Never Wait for a level before NAC in late, staggered or unknown-time ingestions Use the nomogram for staggered ingestions Stop NAC early because the patient looks well Give vitamin K or FFP routinely (INR is a prognostic marker) Common mistakes Waiting for levels Stopping NAC too early Nomogram misuse Missing massive ingestion dosing Disposition and follow-up Ward on NAC; liver unit if criteria met; psychiatry before discharge.
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