Decision Rule - King's College Criteria for Acetaminophen Toxicity

King’s College Criteria for Acetaminophen Toxicity

-Arterial pH <7.30  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No/Yes]

-INR >6.5 (PT >100 seconds) . . . . . . . . . . . . . . . . . . . . . . . .  [No/Yes]

-Creatinine 3.4 mg/dL (300 µmol/L) . . . . . . . . . . . . . . . . . . . . [No/Yes]

-Grade III or IV hepatic encephalopathy  . . . . . . . . . . . . . . . .  [No/Yes]

The presence of any of the above should prompt referral and possible transfer to a center capable of liver transplantation.

Other predictors of a poor prognosis without transplant:

-Lactate >3.5 mmol/L after fluid resuscitation (<4 hours)  . . .  [No/Yes]

-Lactate >3 mmol/L after full fluid resuscitation (12 hours) . .  [No/Yes]

-Phosphate >3.75 mg/dL (1.2 mmol/L) at 48-96 hours . . . . .  [No/Yes]

https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity

https://www.mdcalc.com/hepatic-encephalopathy-grades-stages

MDM - Acetaminophen Overdose

[##]-year-old [male/female] presents with history and exam consistent with acetaminophen overdose [as a suicide attempt/additional].

Initial considerations in this patient included acetaminophen intentional and accidental overdose, other intentional ingestions and co-ingestions including salicylates, alcohol, toxic alcohols, opioids, benzodiazepines, anticholinergic medications, and antidepressant medications including tricyclic antidepressant (TCA) among others, other self-injury, and other infectious and toxicologic etiologies among others.

Patient presented with [suspected/reported] overdose of acetaminophen [## hours/days] prior to presentation.  Patient felt to have [no indication for intubation or more aggressive airway management on presentation/indication for intubation due to altered mental status].  Patient noted to be [unstable with appropriate resuscitation initiated/hemodynamically stable] on presentations.  Gastrointestinal decontamination with activated charcoal [felt to not be indicated given presentation over 3 hours from reported/suspected ingestion/administered in patient presenting within 3 hours from reported/suspected ingestion].  Initial labs were obtained including an ethyl alcohol level, salicylate level, [others] and liver function tests, which were [noted to be unremarkable/notable for elevated hepatic enzymes/specify].  A 12-lead EKG was obtained [with no evidence of acute ischemia, infarction or other QRS, ST, or T wave changes associated with tricyclic antidepressant overdose/notable for specify abnormality].

An [initial/4-hour] acetaminophen level was obtained and [noted to be elevated based on Rumack-Matthew nomogram/noted to be elevated in the setting of unknown time of ingestion].  Treatment with N-acetylcysteine (NAC) initiated via [oral/intravenous] route along with supportive care as noted above.  Patient felt to have [no] indication for transfer to transplant center by King's Criteria at this time.

Case discussed with [ICU team/admitting hospitalist and Poison Control] with plan for admission to the [ICU/telemetry unit/etc.].  Planned admission and treatment [was/was not] discussed with the patient [who demonstrated understanding and agreement with plan/who is involuntary for admission at this time/due to altered mental status].

https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity
https://edsmartchart.blogspot.com/2020/06/decision-rule-kings-college-criteria.html
http://www.emdocs.net/toxcard-acetaminophen-toxicity-and-management/