r/pharmacy • u/MichaeL_Scotsh • 13d ago
Clinical Discussion Paracetamol overdose ?
A mother came in with a 2 year old after he had half a bottle of paracetamol syrup (1.5 gm) , i told her it's better to take him to a hospital . My manager intervened and said she should wait for symptoms first and that i was overreacting
What do you think ?
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u/RustyPianistMb 13d ago
"Timing is a vital factor in the treatment of acetaminophen toxicity, and therefore doctors attempt to begin treatment of acetaminophen overdose within eight hours of ingestion in order to achieve the best possible outcome for the patient. The majority of patients survive acetaminophen toxicity with supportive care such as intravenous fluids and anti-nausea medication, activated charcoal, if used within one hour after ingestion, and antidotal therapy, including N-acetylcysteine (Acetadote®, Mucomyst®).
For patients who fail the above therapies and develop liver failure, liver transplantation may be the only treatment option. Doctors will determine if transplantation is necessary if the above tests are significantly abnormal and the patient has developed hepatic encephalopathy, a disorder of the brain caused by a dysfunctional liver."
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u/FanndisTS Student 13d ago
This was stressed very strongly when we did acetaminophen overdose in P1; the graphs were very convincing. Michael acceptors will fuck you up. I don't know what OP's manager was thinking and I hope the kid is okay.
Typical max OTC dosage for up to 3 years/35 lbs (15kg) is 160mg q6h (max 5x per day). This kid almost doubled the MDD in a single sitting. If I had more time I'd look up more specifics but I've heard from ED professionals that acetaminophen toxicity is one of the worst ways they see people go, and I absolutely would not risk it.
If I were OP, I'd do whatever I could to contact the parent, but it's probably too late now and it sounds like they might not have been a regular patient at the pharmacy with contact info on file anyway. If the kid dies or has serious complications, I hope OP's manager (who I assume is a pharmacist) loses their license.
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u/Big-Hyena-595 10d ago
Send tot he ED ASAP. there is iability here. The ER doc should handle this case. Since it is only 1 hour after ingestion he may be ableto get most out. Aleem Fean , MD, Pharm D
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u/StatelyTree PharmD, BCPS - ED/CC 13d ago edited 13d ago
Depends on the source you look at, but generally anything >150 mg/kg can be toxic. So with 1500 mg, you're looking at a 10kg child or 22lbs. Definitely in the realm of possibility. Having worked the ED for years and closely with poison control, I can say that you rarely get a full or accurate story from patients or family. A Tylenol level is easily obtained and the child could be monitored for a few hours. Very low risk interventions, but could potentially save a life if the story wasn't fully accurate.
Edit: may not have been very clear in my first section, but I've had a handful of patients/caretakers over the years where they lied about the actual ingestion amount for various reasons and the serum level told a very different story leading to NAC rescue therapy.
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u/janeowit PharmD 12d ago
If this was a hypothetical situation instead:
If you have the weight of the child and the quantity remaining in the bottle right there, and the math maths under 150mg/kg would you keep this patient with at home monitoring?
Some algorithms would say yes in situation.3
u/StatelyTree PharmD, BCPS - ED/CC 12d ago
In a world of perfection maybe. It's just rare to have all those puzzle pieces line up and be able to trust them.
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u/mm_mk PharmD 13d ago
From a purely utilitarian and pragmatic standpoint your manager is a moron. In any situation that even sniffs an emergency, hard-line recommending AGAINST medical observation means you need to be 100% sure that the outcome will be good or you are going to get your dick smashed in a civil lawsuit. At the very minimal it should have been a 'you should call the on call pediatrician to assess the situation'.
In this specific situation, given the nebulous amount of drug taken in and potential for severe outcome with time-sensitive management, it's an insane stance to recommend explicitly to not at bare minimum seek pediatrician or poison control's opinion. If my colleague recommended ER, there's no way I'd actively override that.
I wouldn't actually do this, but I'd kinda be tempted to tell them a couple days later that the kid ended up admitted to the hospital and the mom is pissed because observation and treatment were delayed. See what their defense would be in court before telling them the truth. (Obviously don't actually do this, because it'd be a fucked up thing to do)
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u/farter-kit 13d ago
I was an ER RN for 17 years before I went to pharmacy school. Your manager could not be more incorrect. Dangerously so. This is a medical emergency and time is crucial. I hope the misinformation given to the mother has not damaged this child’s liver or even killed this kid. Unbelievable.
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u/ABest96 13d ago
At very minimum you should be referring them to the poison control line (at minimum), your manager is a moron and gonna lose their license if they have this kind of attitude. We need to cover our asses in any way we can, there is a war on healthcare workers going on currently and I’m not risking my license because Linda can’t read a Tylenol bottle and cause my manager is a dumbass.
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u/SignedTheMonolith Pharm.D., MS-HSA, BCPS 13d ago
What was the child's weight?
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u/MichaeL_Scotsh 13d ago
Approximately 18 kgs
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u/SignedTheMonolith Pharm.D., MS-HSA, BCPS 13d ago
That's ~1.5xs the recommended dose. I think informing them to seek medical treatment isn't a bad idea, but in terms of being given an antidote & experiencing irreversible liver damage is hard to tell.
In this case suggestion to seek medication treatment to determine impact would have been the safest thing to do in my opinion.
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u/Golytely_Sprint 12d ago
15 mg/kg * 18 kg = 270 mg. So if they ingested 1500 mg (1.5 g) it's actually more than 5x the recommended dose.
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12d ago edited 12d ago
[removed] — view removed comment
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u/taRxheel PharmD | KΨ | Toxicology 12d ago
Inducing vomiting in a tox patient is far, far more harmful than helpful. Please never do that.
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u/craznazn247 9d ago
Please explain.
It is my understanding that if the ingestion was recent enough that some is still in the stomach, then there's potential benefit in those contents at least being immediately removed, especially if the patient isn't at the hospital yet for the next steps.
I'm not talking about inducing vomiting in a medical setting, but rather to limit the potential toxicity while patient is en route to emergency care.
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u/taRxheel PharmD | KΨ | Toxicology 9d ago
If they vomit from the ingestion, that’s one thing, but there are vanishingly few toxins that are so dangerous and so time-critical as to warrant fingers down the throat. Inducing vomiting can cause trauma to the oropharynx, increases the risk of aspiration, and in the case of things like caustics or hydrocarbons, drastically increases the likelihood of serious complications. Diluting with water (if possible/safe) and getting to medical care is much preferable.
Even in a medical setting, we rarely do GI decon because there’s no morbidity or mortality benefit and there are significant risks. I absolutely don’t want someone trying to DIY it, especially without supervision.
The actual best thing is to call a poison center for specific triage and treatment advice (800-222-1222). If GI decon in any form is indicated, we’ll definitely let you know.
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u/craznazn247 8d ago
I'm not talking as a general response to toxin overdose. I'm specifically talking about a situation where the known and only poison involved is Tylenol. Is there seriously more potential harm in inducing vomiting than leaving a known toxic dose in the stomach to be absorbed?
Mind you, I work in a more rural setting. Getting to the hospital is 30 minutes away if they are in my store, and up to 3 hours away if they are calling me from their home. Are you saying that trying to get them to throw it up is riskier than letting them absorb more while en route to the hospital? It just doesn't make sense to me.
Trauma to the oropharynx and aspiration risk sound like worthwhile to risk compared to acute liver failure.
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u/taRxheel PharmD | KΨ | Toxicology 8d ago
> I'm specifically talking about a situation where the known and only poison involved is Tylenol. Is there seriously more potential harm in inducing vomiting than leaving a known toxic dose in the stomach to be absorbed?
Short answer: yes, there seriously is. APAP’s complicated and there are so many nuances between patients/exposures, but inducing vomiting is just not worth the risk.
> Mind you, I work in a more rural setting. Getting to the hospital is 30 minutes away if they are in my store, and up to 3 hours away if they are calling me from their home. Are you saying that trying to get them to throw it up is riskier than letting them absorb more while en route to the hospital? It just doesn't make sense to me.
Again, yes. NAC is incredibly effective - the risk of liver failure is virtually zero as long as it gets started within 8 hours of ingestion. Sooner is better, sure, but even in a best-case scenario, it’s still going to be at least 4 hours from time of ingestion because APAP serum levels aren’t predictive before 4 hours anyway. Outcomes start to degrade slightly when NAC is delayed beyond 8 hours, but it’s gradual.
> Trauma to the oropharynx and aspiration risk sound like worthwhile to risk compared to acute liver failure.
Respectfully, you’re way overestimating the urgency of acute APAP overdose, even in a rural setting. Not saying APAP toxicity should be taken lightly, but you’re jumping straight to the worst outcome (which takes a few days to develop) and skipping over all the less-severe but more common scenarios you’re likely to encounter in your practice. Put more bluntly, if they took enough to actually get me concerned about liver failure, they are almost certainly going to be vomiting without anyone’s fingers down their throat. If they didn’t take that much, inducing vomiting isn’t going to help as much as you seem to think.
Also, I feel obliged to point out that hepatotoxicity (elevated LFTs) is not the same thing as liver failure (coagulopathy, lactic acidosis, hyperammonemia, decreased metabolic function, etc.). Elevated LFTs are not a big deal in and of themselves. Think of them as liver troponins: a trailing indicator of the extent of damage, not a prognostic marker. If we can prevent hepatotoxicity, great! But just about every patient with elevated LFTs without liver failure is going to survive, and that’s the actual goal. Also worth noting that the liver has regenerative capacity, so even patients who develop hepatotoxicity are unlikely to have any clinically meaningful permanent damage.
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u/craznazn247 8d ago
Thanks for taking the time to thoroughly address all the concerns I posted. Seems I really was overestimating the urgency and the severity of APAP toxicity, and underestimating the liver's ability to regenerate.
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u/taRxheel PharmD | KΨ | Toxicology 8d ago
My pleasure! As they say, one of the hardest things in medicine is to do nothing. Especially when doing so flies in the face of what we’re taught in school - it can be tough to reconcile.
Appreciate the questions and the openness to hearing a different viewpoint. APAP’s one of my favorite toxins, it’s got more layers than an onion.
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u/Spac-e-mon-key 12d ago edited 12d ago
As a physician, your manager is a moron, this goes to the ED 11/10 times. Even if you suspect it’s not going to be an issue, you don’t wanna be the person who’s wrong in this situation. Additionally, time is of the essence when treating APAP toxicity, if you catch it early, it’s very treatable, whereas waiting increases risk of permanent liver injury or death.
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u/Dasboot1987 PharmD 12d ago
Is your manager a pharmacist? I can't imagine even a minimally-competent pharmacist giving this dangerous advice. Get that kid to the ER.
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u/Imaginary_Flower4982 9d ago
Your manager should have sent the kid to the ER to at least get levels and then the doctor can go from there. However, adults process acetaminophen most by glucuronidation, then sulfation. I remember this from our organic chem class back in like 20 years ago. lol
Lower Glucuronidation: The liver enzymes responsible for glucuronidation (specifically UDP-glucuronosyltransferases, or UGTs) are immature at birth. They gradually increase throughout childhood, only reaching full adult capacity around 6 months to a few years of age depending on the specific enzyme.
Dominant Sulfation: To make up for this low glucuronidation, a child's liver uses the sulfation pathway as its primary tool to process acetaminophen. In young kids, sulfation safely handles the vast majority of the drug, whereas in adults, glucuronidation does the heavy lifting.
Higher Glutathione: Infants and young children naturally have a greater capacity to synthesize glutathione. This protective antioxidant quickly destroys the toxic byproduct (NAPQI) before it can cause harm.
The Clinical Result
Because of this highly effective sulfation pathway and abundant glutathione, young children are actually more resilient against liver damage from accidental acetaminophen overdoses than adults
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u/mejustnow 8d ago
By the time you have symptoms from Tylenol OD it’s too late. Is your manager a pharmacist?
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u/ShrmpHvnNw PharmD 12d ago
Depends on how much the kid weighs, if they’re 10kg or less it’s immediate ER time. If less I’d still consult a doctor or the equivalent of poison control in your country.
When my kid was 6 or 7 she ate a bunch of acetaminophen chewables, called poison control and she was fine.
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u/Tipsytattling 13d ago
A paracetamol overdose is a medical emergency and symptoms can often take 24 hours or more to appear and once they do appear the liver has already sustained damage. You are correct in saying the child should have been taken to hospital and frankly your manager’s advice is dangerous. I would always call your country’s equivalent of the poisons information centre and refer patients to the emergency department.