A 16-year-old girl ingests an estimated 12 g of paracetamol in a suicide attempt. She presents 10 hours later feeling well, with normal liver function tests. Plasma paracetamol concentration plots above the treatment line on the Rumack-Matthew nomogram. What is the most appropriate management?
- A Reassure and discharge, since liver enzymes are normal
- B Induce emesis and repeat the level in 4 hours
- C Start N-acetylcysteine infusion immediately ✓
- D Start oral methionine alone and observe for 48 hours
Correct answer: C. Start N-acetylcysteine infusion immediately
Explanation
A level above the treatment line mandates N-acetylcysteine regardless of how well the patient looks, because transaminase rise lags behind injury by 24 hours or more. NAC replenishes glutathione, is maximally protective within 8 hours, but still reduces mortality when started up to 24 hours or later. Normal early LFTs never exclude impending fulminant hepatic failure, which kills distractor A.
Reference: Goldfrank's Toxicologic Emergencies, 11th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.