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Paracetamol overdose in children: management following an initial N-acetylcysteine regimen
  1. Nikitha Rajaraman1,
  2. Laurence Gray2,
  3. Mark Anderson3,
  4. Chayarani Kelgeri4
  1. 1 Paediatrics and Neonatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
  2. 2 National Poisons Information Service (Cardiff Unit), University Hospital Llandough, Llandough, UK
  3. 3 National Poisons Information Service (UK), Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
  4. 4 Liver Unit, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, Birmingham, UK
  1. Correspondence to Dr Nikitha Rajaraman, Paediatrics and Neonatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B95ss, Birmingham, UK; nikitha12.rajaraman{at}

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Key points

  • Blood tests that guide management of paracetamol overdose (POD) include alanine aminotransferase, aspartate aminotransferase, bilirubin, urea, creatinine, electrolytes, clotting profile, blood gas, glucose, lactate and paracetamol concentration.

  • Coagulopathy (international normalised ratio >2, Prothrombin time> 20 s) in children with POD indicates acute liver failure (ALF) and is managed with continuation of N-acetylcysteine, instituting ALF protocol ( and contacting the tertiary liver unit.

  • In cases of intentional POD, mental health and safeguarding assessments are integral parts of the medical management.


A 14-year-old girl presents to the emergency department 6 hours following an intentional acute paracetamol overdose (POD). She confesses to having recent suicidal ideation following a fall-out with her boyfriend.

Blood tests reveal a paracetamol concentration of 235 mg/L, with normal pH and lactate on blood gas, normal transaminases, urea, creatinine and coagulation profile. The attending clinician, following a risk assessment, admits her and informs the Child and Adolescent Mental Health Services (CAMHS) and the safeguarding team. The paracetamol concentration is above the treatment threshold on the paracetamol nomogram1 and she is managed as per the TOXBASE protocol1 with N-acetylcysteine (NAC) infusion. Before the end of the last bag of NAC infusion, repeat blood tests show an international normalised ratio (INR) 1.9, alanine aminotransferase (ALT) 324 IU/L, pH 7.35 and lactate 2.3 mmol/L (reference range,2 table 1). What do we do next?

View this table:
Table 1

Reference range for blood tests in children (RCPCH)

POD is a common presentation and if not treated promptly, can lead to irreversible liver failure which may necessitate liver transplant or be fatal in some cases. The initial management is as per the National Poisons Information Service (NPIS) recommendations within TOXBASE. If blood tests following treatment are within reference ranges, the management is straightforward. However, difficulty arises when faced with persistent transaminitis, clotting derangement, acute kidney injury (AKI) or lactic acidosis following …

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  • Contributors CK devised the main conceptual idea and supervised this project. NR planned the outline of the article, reviewed relevant evidence and research on this topic, devised the guideline explained within the article with input from CK and wrote the manuscript. CK, LG and MA provided expert opinion, proof-read a few drafts of the manuscript and strengthened the quality of the article. All authors provided inputs for the writing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.