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Acetaminophen (APAP) is one of the most common causes of pharmaceutically associated poisoning and death in the United States annually. Shortly following acetaminophen overdose, patients are often asymptomatic; therefore an APAP level should be obtained with all suspected ingestions. Administer empiric N-acetylcysteine (NAC) to patients (1) who may have ingested a toxic amount of APAP and (2) for whom the estimated time of ingestion is close to or greater than 8 hours and delay while waiting for a level may or will result in treatment beginning greater than 8 hours after ingestion.


Illness from acetaminophen overdose is caused primarily by liver damage.

  • Acetaminophen is primarily metabolized by the liver. Too much acetaminophen can overwhelm the way the liver normally functions.
  • Full and long time use of acetaminophen in recommended doses has not been shown to be harmful to the liver, even when combined with moderate alcohol consumption.


  • Early (first 24 hours): initial toxicity is often mild or overlooked, consisting of anorexia, nausea, vomiting, and malaise.
  • Late (24 to 72 hours after ingestion): symptoms of liver failure (e.g., recurrent nausea, vomiting, and malaise, abdominal pain, lethargy, confusion)


  • Early: none
  • Late (24 hours): right upper quadrant tenderness
  • Signs of fulminant hepatic and multiorgan system failure (e.g., confusion, coma, tachypnea, jaundice, asterixis) may ensue from 24 to 96 hours in those not treated or treated too late.


If someone is suspected of having taken an overdose but has no symptoms, the doctor will begin the following treatment:

  • Emptying of the stomach: Few cases in which a person comes to the hospital minutes after taking the overdose, the doctor may attempt to empty the stomach. This can be accomplished by inducing vomiting or by placing a large tube through the person's mouth and into the stomach.
  • NAC is stand by N-acetylcysteine. NAC is the antidote for toxic acetaminophen overdose. It is generally given by mouth. The medication has a foul odor but may be mixed with juice or other flavorings to make it taste better. If the person cannot take NAC by mouth, a tube may be placed through the mouth and into the stomach to help administer it. If giving NAC by this method is not possible, the doctor may give it by IV. NAC is given for 20-72 hours.

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