A 30-year-old woman is brought to the emergency department 4 hours after ingesting approximately 25 g of paracetamol (acetaminophen) in a suicide attempt. She is asymptomatic with normal vital signs and normal liver enzymes at presentation. Which is the most appropriate immediate management?

• A Observe for 24 hours and start N-acetylcysteine only if transaminases rise
• B Start intravenous N-acetylcysteine immediately while awaiting the 4-hour serum level ✓
• C Activate charcoal if within 1 hour, then check level at 4 hours; start NAC if above the line
• D Initiate urgent hemodialysis to remove the drug

Explanation

With a potentially toxic single acute ingestion within 8 hours and presentation at 4 hours, intravenous N-acetylcysteine should be started immediately without waiting for the paracetamol level, as its efficacy is time-dependent and best within 8 hours. Activated charcoal is only useful within 1 to 2 hours. Hemodialysis is not indicated for paracetamol overdose unless massive ingestion with metabolic acidosis. Observation without NAC is unsafe given the high-risk dose.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.