GI decontamination
Activated Charcoal if <3 hr post-ingestion (no role for multidose activated charcoal)
Gastric Lavage if high-morbidity coingestants and <1 hr post-ingestion
Send 4hr APAP level
Toxic level: Give NAC
Nontoxic level: No treatment necessary
Activated Charcoal if <3 hr post-ingestion (no role for multidose activated charcoal)
Gastric Lavage if high-morbidity coingestants and <1 hr post-ingestion
Toxic level: Give NAC
Nontoxic level: No treatment necessary
Send APAP level
If level will be available within 8hr post-ingestion: wait for level before treating
If level will not be available within 8hr post-ingestion: do not wait for level before treating
Discontinue treatment if level returns non-toxic
If level will be available within 8hr post-ingestion: wait for level before treating
If level will not be available within 8hr post-ingestion: do not wait for level before treating
Discontinue treatment if level returns non-toxic
Discontinue treatment if level returns non-toxic
Consider GI decontamination for unknown ingestion time
Give 1st dose of NAC
Send APAP level, LFT, coags
APAP level >10 OR elevated transaminases? If yes then continue NAC
pH <7.3 or PT >100 or creatinine >3.3 or altered mental status? If yes refer to liver transplant unit
APAP level <10 and LFT both normal? If yes then stop NAC (treatment not indicated)
APAP level >10 OR elevated transaminases? If yes then continue NAC
pH <7.3 or PT >100 or creatinine >3.3 or altered mental status? If yes refer to liver transplant unit
APAP level <10 and LFT both normal? If yes then stop NAC (treatment not indicated)
pH <7.3 or PT >100 or creatinine >3.3 or altered mental status? If yes refer to liver transplant unit
Initiate NAC in any patient with evidence of ongoing hepatotoxicity (lft abnormalities) OR 'positive' tylenol level (>20 mcg/mL)
If patient has normal LFT and 'negative' tylenol level (<20 mcg/mL), NAC treatment NOT required
Both IV or oral NAC may be used in pregnant patients with<unk> . 
IV formulation may be preferred to increase fetal NAC concentrations
IV formulation may be preferred to increase fetal NAC concentrations
Extended-release acetaminophen (Tylenol ER) consists of acetaminophen 325 mg in immediate release (IR) form surrounding a matrix of acetaminophen 325mg
Several studies show that the elimination of ER and IR APAP preparations is nearly identical after 4 hours. However, some case reports have documented APAP levels that are above the potential toxicity and treatment line on the nomogram as late as 11-14 hours after the ingestion of the ER preparation.
Recommended management includes the measurement of 4-, 6-, and 8-hour APAP concentrations. Begin NAC therapy if any level crosses above the nomogram treatment line. If the 6-hour level is greater than the 4-hour level, begin NAC therapy.
Several studies show that the elimination of ER and IR APAP preparations is nearly identical after 4 hours. However, some case reports have documented APAP levels that are above the potential toxicity and treatment line on the nomogram as late as 11-14 hours after the ingestion of the ER preparation.
Recommended management includes the measurement of 4-, 6-, and 8-hour APAP concentrations. Begin NAC therapy if any level crosses above the nomogram treatment line. If the 6-hour level is greater than the 4-hour level, begin NAC therapy.
>500mg/kg
May have early acidemia, coma, hemodynamic changes (does not necessarily indicate hepatic damage)
Supportive care (IVF, pressors, intubation PRN)
Early consultation with poison control, prior to 4 hour level
May consider early or increased NAC dosage, dialysis in extreme cases 
Supportive care (IVF, pressors, intubation PRN)
Should begin if:
The patient's history suggests:acetaminophen ingestion of ≥ 150mg/kg in children or 7.5 g in adults and the results of blood tests will not be available within 8 hours of the ingestion or
Serum acetaminophen concentration falls on or above the Rumack-Matthew nomogram treatment line or
While waiting for AST/ALT levels of a patient with a chronic overdose
Serum levels may not reach peak until up to 4 hours post-ingestion
Serum levels may not reach peak until up to 4 hours post-ingestion
Generally the reactions are self limited with symptoms such as pruritis treated with Diphenhydramine. If angioedema develops NAC infusion should be stopped and restarted an hour after symptom resolution.
Acetaminophen toxicity
Acetaminophen toxicity 
Mescaline toxicity
Viral hepatitis
Cocaine toxicity
Hepatitis A
Carbamate toxicity
Hepatitis B