Out-of-hospital assessment and triage of paracetamol (acetaminophen) exposure in the United States and Canada: a consensus guideline

Introduction: Consensus guidelines for out-of-hospital assessment and triage of paracetamol (acetaminophen) exposure were published in 2006. Changes in the healthcare system, paracetamol ingestion trends, and availability of paracetamol-containing products necessitate an update to these guidelines. Updated guidelines were created for out-of-hospital management of paracetamol exposure in the United States and Canada. Methods: A modified Delphi consensus methodology was used to create a decision framework to evaluate clinical aspects of care related to paracetamol overdose in the out-of-hospital setting. Twenty-one panelists were selected by four clinical toxicology societies (America’s Poison Centers®, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association for Poison Centres and Clinical Toxicology) to participate as panelists. Guidelines were collected from most poison centers in the United States and Canada, and systematic collection and review of medical literature was conducted. Results: The panel developed a guideline for out-of-hospital management of paracetamol exposure that encompasses acute and repeated supratherapeutic ingestion patterns. Acute ingestion is defined as any ingestion presenting within 24 h of initial ingestion, regardless of ingestion pattern. Repeated supratherapeutic ingestion is defined as an exposure that occurs over a period of 24 h or more. This guideline emphasizes the importance of obtaining accurate history. When ingestion history is determined as accurate, dosage and ingestion pattern are used to decide treatment referral. It is recommended that patients be referred to the emergency department if their ingestion amount is: (1) ≥200 mg/kg or 10 g (whichever is less) within 24 h; (2) ≥150 mg/kg/24 h or 6 g/day (whichever is less) within 48 h; (3) ≥100 mg/kg/24 h or 4 g/day (whichever is less) for more than 48 h. Discussion: The need for standardizing the out-of-hospital assessment and triage of paracetamol exposure is pressing. Despite the availability of acetylcysteine, some patients develop fatal liver failure due to missed diagnoses and delays in treatment. Failure to recognize cases requiring acetylcysteine is associated with significant morbidity and mortality. Conclusion: This consensus statement provides evidence-based guidance for out-of-hospital management of paracetamol ingestion to standardize healthcare facility referral criteria for paracetamol exposed patients.