Adult Medical Emergency Handbook - Scottish Intensive Care Society

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treatment schedule should be used even if patients have a history
of a reaction to a previous N-acetylcysteine infusion.
PRESENTATION 8-15 HOURS POST INGESTION
• If >150 mg/kg (or >12g) or >75 mg/kg in a high risk patient has
been ingested start N-acetylcysteine immediately (see Adult
Dosing Schedule above)
• Check FBC, U&Es, LFTs and prothrombin time (INR) and
paracetamol concentration
• If paracetamol concentration is below treatment line, blood tests
are all normal and the patient is asymptomatic discontinue NAC.
Otherwise continue with the normal infusion protocol.
PRESENTATION 15 –24 HOURS
Patients presenting late are at greatest risk of developing
liver damage.
• If >150 mg/kg (or >12g) or >75 mg/kg in a high risk patient has
been ingested start N-acetylcysteine immediately
• Check FBC, U&Es, LFTs and prothrombin time (INR) and
paracetamol concentration
• The paracetamol concentration is less reliable at this time, and
the presence of an elevated prothrombin time and ALT are better
markers of possible liver damage
• If paracetamol is below treatment line, blood tests are all normal
and the patient is asymptomatic, N-acetylcysteine can be
discontinued. Otherwise continue with the normal infusion protocol.
PRESENTATION >24 HOURS
Patients presenting late are at greatest risk of developing
liver damage.
• Check FBC, U&Es, LFTs and prothrombin time (INR)
• If investigations are normal, and the patient is asymptomatic no
further medical treatment is required
• If abnormal give N-acetylcysteine
• Patients require frequent monitoring of U&Es (including
bicarbonate), LFTs, INR, lactate and glucose
• Progressively rising INR and ALT, metabolic acidosis, renal
262 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11