Paracetamol poisoning can cause severe liver damage. If an overdose is suspected, the patient should be transferred promptly to a unit where examination and treatment can be performed with monitoring.
A national or otherwise relevant poison information center should be consulted without hesitation.
Liver enzymes and paracetamol levels should be measured.
Treatment with acetylcysteine should be started immediately in the case of severe poisoning, otherwise depending on the paracetamol concentration.
Paracetamol alone or as a causative agent in mixed poisoning is one of the most common causes of severe drug poisoning.
Severe poisoning is in most cases deliberate.
Combination products (with codeine, for instance) can cause parallel paracetamol poisoning in people looking for opioids.
Acute liver damage of originally unknown cause is often due to paracetamol.
A dose of paracetamol ≥ 150 mg/kg is hepatotoxic.
For adults weighing 70 kg, more than 10 g within 24 h or more than 6 g daily for at least 2 days
Even smaller amounts may damage the liver in risk groups (alcohol dependence, HIV, undernutrition, liver failure or high aminotransferase concentrations, medication affecting hepatic metabolism, poor diuresis).
Because of the slow emergence of liver damage, low serum paracetamol levels do not exclude paracetamol as the causative agent.
Special attention is required in poisoning caused by slow-release paracetamol preparation (so-called "Extend" products), where the concentration may increase even for a very long time and the kinetics do not follow the nomogram.
Symptoms and findings
Primary symptoms and findings (0-24 h)
Nausea, vomiting, abdominal pain
Hypokalaemia and metabolic acidosis
Later symptoms (24-72 h)
Abdominal pain, liver tenderness
Increased aminotransferase levels as a sign of hepatocellular injury; PT% decreasing (INR and PT [in seconds] increasing) and at its lowest at 3-4 days, unless the liver regenerates.