This is a draft cheat sheet. It is a work in progress and is not finished yet.
4 Phases of APAP Toxicity
Phase 1
(1-24 hrs) |
- Commonly asymptomatic or
- Non-specific (N/V) |
Phase 2
(24-48 hrs) |
- Labs show hepatotoxicity
- Increase INR
- Increase AST/ALT
- Phase 1 symptoms subside |
Phase 3
(48-96 hrs) |
- Fulminant liver failure
- Jaundice
- Encephalopathy
- Coagulopathy
- hepa-to-renal syndrome |
Phase 4
(>96 hrs) |
- Pt either
- Recovers
- Dies
- Receives liver transplant |
APAP Explanation of Chart on Pg 270
NAPQI
N-acetyl-p-benzoquinone-imine |
APAP undergoes CYP2E1 (only with excessive doses) and produces NAPQI (toxic) |
Antidote |
NAC (N-acetylcysteine) |
NAC |
↑ glutathione = ↑ GSH (glutathione-S-traferase) |
GSH |
Converts NAPQI to mercapturic acid (excretes safely from the body) |
Rumack Matthew Nomogram |
APAP blood levels are drawn and plotted on this |
APAP Toxicity Tx
N-Acetylcysteine |
Oral |
- 140 mg/kg x 1 followed by
- 70 mg/kg Q4H x 17 doses
- Repeat dose if emesis occurs within 1 hr of administration |
IV |
- 150 mg/kg IV x 60 mins followed by
- 50 mg/kg IV x 4 hrs followed by
- 100 mg/kg IV x 16 hrs |
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Opioid Overdose Symptoms
- Slowed breathing (respiratory depression) |
- Pinpoint pupils |
- Altered mental status |
- Unconsciousness (sedation) |
- When in doubt give naloxone
Opioid Toxicity Tx
Naloxone |
How it works |
- If administered quickly, naloxone reverses depressant effects of opioids |
Naloxone AE: |
- Little to none if no opioids were ingested |
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