BNF for Children 2011-2012

BNFC 2011–2012 Emergency treatment of poisoning 27Emergency treatment of poisoningPatients whose plasma-paracetamol concentrations are on or above the normal treatment line should be treatedwith acetylcysteine by intravenous infusion (or, if acetylcysteine cannot be used, with methionine by mouth,provided the overdose has been taken within 10–12 hours and the patient is not vomiting).Children at high-risk of liver damage include those:. taking liver enzyme-inducing drugs (e.g. carbamazepine, phenobarbital, phenytoin, primidone, rifampicin,rifabutin, efavirenz, nevirapine, alcohol, St John’s wort);. who are malnourished (e.g. in anorexia or bulimia, cystic fibrosis, hepatitis C, in underweight childrenwith failure to thrive, in alcoholism, or those who are HIV-positive);. who have a febrile illness;. who have not eaten for a few days.These children should be treated if their plasma-paracetamol concentration is on or above the high-risktreatment line.The prognostic accuracy after 15 hours is uncertain but a plasma-paracetamol concentration on or above therelevant treatment line should be regarded as carrying a serious risk of liver damage.Graph reproduced courtesy of University of Wales College of Medicine Therapeutics and Toxicology Centreis an alternative if intravenous access is not possible—contact the National Poisons Information Service foradvice. In remote areas, methionine by mouth is analternative only if acetylcysteine cannot be givenpromptly. Once the child reaches hospital the need tocontinue treatment with the antidote will be assessedfrom the plasma-paracetamol concentration (related tothe time from ingestion).Children at risk of liver damage and therefore requiringtreatment can be identified from a single measurementof the plasma-paracetamol concentration, related to thetime from ingestion, provided this time interval is notless than 4 hours; earlier samples may be misleading.The concentration is plotted on a paracetamol treatmentgraph, with a reference line (‘normal treatmentline’) joining plots of 200 mg/litre (1.32 mmol/litre) at