Acetaminophen Toxicity

34 yo M with DM, HTN, DVT on coumadin presenting with a perirectal abscess and was subsequently found to have markedly elevated LFT’s (ALT – 3300, AST – 380).  On further history, it was found that the patient was taking Vicodin (acetaminophen + hydrocodone) multiple times daily due to the rectal pain.

Patient was diagnosed with a chronic acetaminophen overdose and was treated with N-acetyl-cysteine.

Today’s Teaching Points:

1) Transaminases > 1000 generally mean toxin, ischemia or acute viral hepatitis

2) Rumack-Matthew nomogram is very useful in acute acetaminophen ingestion (i.e. taking 100 pills at once), but does not help in chronic Tylenol ingestions.

3) Acetaminophen overdose is the most common cause of acute hepatic failure requiring transplant in the USA. Be very careful with your Percocet, Vicodin and Tylenol #3 prescriptions!

4) N-acetyl-cysteine is most useful in the first 8 hours following an acute acetaminophen ingestion.

NEJM Clinical Practice – Acetylcysteine for Acetaminophen Poisoning (N Engl J Med 2008; 359:285-292)