A 35-year-old female presents with nausea, vomiting, and severe abdominal pain. She reports that earlier in the day, she had been feeling very unwell due to flu-like symptoms and a headache, for which she took paracetamol. She does not remember how many she took but suspects it may have been more than the recommended limit, starting at 8 am that morning.


Her observations are within the normal range. She appears pale and malnourished with right upper abdominal tenderness, enlarged liver, and pain on deep inspiration. Blood tests show deranged liver function with ALT twice the upper limit.


Which of the following is the best next step in the management of this patient?

Options:
explanation: This patient's symptoms and examinations are consistent with a paracetamol overdose. Naloxone is used for an opioid overdose, not a paracetamol overdose. This patient's symptoms, including nausea, vomiting, severe right upper abdominal pain, and a history of taking paracetamol, are more in line with an acute paracetamol overdose and liver injury. These symptoms do not fit an opioid overdose; symptoms such as respiratory depression, pinpoint pupils and altered mental status would be expected.
name: Treat with naloxone immediately
label: e
answer: no
explanation: This patient's symptoms and examinations are consistent with a paracetamol overdose. More than eight hours have passed since the paracetamol ingestion, so the benefit of activated charcoal in reducing absorption is significantly diminished. Only if the paracetamol overdose occurred less than 1 hour ago, should activated charcoal be administered instead of N-acetylcysteine. The patient's clinical presentation, including severe right upper abdominal pain, an enlarged liver, and elevated ALT, is concerning for potential paracetamol-induced liver injury. Specific antidote therapy (N-acetylcysteine) should be given immediately.
name: Treat with activated charcoal immediately
label: b
answer: no
explanation: This patient's symptoms and examinations are consistent with a paracetamol overdose. More than eight hours have passed since the paracetamol ingestion, so the benefit of activated charcoal in reducing absorption is significantly diminished. Only if the paracetamol overdose occurred less than 1 hour ago, should activated charcoal be administered instead of N-acetylcysteine. The patient's clinical presentation, including severe right upper abdominal pain, an enlarged liver, and elevated ALT, is concerning for potential paracetamol-induced liver injury. Specific antidote therapy (N-acetylcysteine) should be given immediately.
name: Conduct a psychosocial assessment
label: d
answer: no
explanation: This is the correct answer. Her symptoms and examination findings are consistent with a paracetamol overdose, although she does not remember how many pills she has taken. The time of ingestion has been more than 8 hours, and she also appears malnourished. Therefore it is the safest option to start administering N-acetylcysteine immediately. The effectiveness of NAC in preventing or mitigating liver damage is highest when administered early, ideally within the first 8-10 hours after overdose. This can help prevent liver damage and reduce the risk of progression to severe liver injury and failure.
name: Treat with N-acetylcysteine immediately
label: a
answer: yes
explanation: This patient's symptoms and examinations are consistent with a paracetamol overdose. The reason to not wait until 12 hours after ingestion and order more laboratory tests is related to the urgency of treating paracetamol overdose effectively. The efficacy of the antidote for paracetamol overdose, N-acetylcysteine (NAC) is time-sensitive. NAC is most effective when administered early, within the first 8-10 hours after the overdose. Waiting until 12 hours after ingestion may significantly reduce the effectiveness of the antidote, and liver damage could progress.
name: Order more laboratory tests and wait until 12 hours after ingestion
label: c
answer: no

Correct answer: a

Treat with N-acetylcysteine immediately