Case 4 - Paracetamol Overdose

Question 1

Common symptoms of paracetamol poisoning

Answer 1

• Non initially/vomitting +/- RUQ pain
• Then later - jaundice, encephalopathy from liver damage, +/- AKI

Question 2

Investigations for paracetamol overdose

Answer 2

• Blood glucose
• U+Es
• LFTs
• Clotting
• ABG
• FBC
• Blood paracetamol level (esp 4hr post ingestion)

Question 3

Clinical guideline/tool to determine specific treatment for paracetamol overdose if indicated?

Answer 3

• If outside normal parameters - national poisons information service/TOXBASE
• Plasma paracetamol conc over time graph with treatment line - if on or above/staggered overdose (>1hr), 8-24hrs more than 150mg/kg, or more than 24hrs since and jaundice, hepatic tenderness and raised ALT - treat

Question 4

Criteria of Kings college hospital for Liver transplant

Answer 4

• Arterial pH less than 7.3 24hrs after ingestion

Or all of:
* PT more than 100s
* Creatinine more than 300umol/L
* Grade III or IV encephalopathy

Question 5

Specific treatment for paracetamol overdose and what MOA?

Answer 5

• Acetylcysteine
• Donates thiol group for glutathione to be produced
• = conjugates NAPQI
• Drives Phase 2 metabolism in liver

Question 6

How to conduct mental state exam?

Answer 6

• Appearance - hygieve, clothing, self harm evidence, IV drug use etc
• Behaviour - engaged? eye contact? facial expression, body language
• Speech - rate, quantitiy, fluency and rhythm
• Mood - what pt tells you they feel
• Affect - mood you observe
• Thought - insertion, withdrawal, broadcast
• Perception
• Cognition - AMTS, MMSE
• Judgement and insight
• Risk

Question 7

Criteria for safe discharge once self harm

Answer 7

• Determine if intentional
• If yes - need to be reveiwd by specialist for psychosocial assessment (MH worker, social worker)
• Medically fit?
• Assess risk to suicide/self harm
• Crisis team number
• Support available offered - harmless, Mind, national self harm network, Samartians
• Safeguarding?
• Urgent referral to secondary MH services/community/drug/alcohol services
• Emotional support family
• F/u within 48hrs
• Prescriptions review - decrease amount prescribed at one time etc
• Keep MDT informed
• Prevent access to self harm medications etc