A 14-year-old ingests an estimated 15 g of paracetamol 6 hours ago. Her serum paracetamol concentration plots well above the treatment line on the Rumack-Matthew nomogram. She is asymptomatic. What is the most appropriate management?
- A Observation with repeat liver function tests at 24 hours, no antidote
- B Start N-acetylcysteine infusion immediately ✓
- C Induce emesis with ipecac syrup and then observe
- D Start oral methionine only if transaminases rise after 24 hours
Correct answer: B. Start N-acetylcysteine infusion immediately
Explanation
A level above the treatment line on the Rumack-Matthew nomogram mandates N-acetylcysteine, which replenishes glutathione and detoxifies NAPQI. Its protective effect is greatest when started within 8 hours of ingestion, so waiting for symptoms or transaminase elevation forfeits the window of maximal benefit. Asymptomatic patients can still develop fulminant hepatic failure 24 to 72 hours later. Ipecac-induced emesis is no longer recommended in any acute poisoning.
Reference: Nelson Textbook of Pediatrics, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.