Let’s move on to tylenol toxicity or acetaminophen toxicity this is incredibly common we see it all the time and we frequently see it in adolescents who are attempting suicide it can also happen as a result of too frequent dosing in young infants who have fever with overly concerned parents so typically a dose of acetaminophen may be toxic if more than 150
Milligrams per kilo has been given or in young children if they’re getting repeated overdoses tylenol when it gets into the body first burns through the body’s glutathione so glutathione is in our system in our liver and it’s allowing the liver to degrade the toxic phenomenon that is acetaminophen once that glutathione is used up the acidity then starts causing
Liver toxicity so we can tolerate small doses not large doses it typically occurs in patients who have ingested a large dose of medication or infants who are getting small doses or even normal doses at too frequent on the interval for too long of a period of time so patients usually have abdominal pain and nausea when they take too much tylenol we’re going to
Use a nomogram to determine if treatment is indicated so here’s the nomogram so typically what we do is we draw a level of tylenol level right and we look in the plasma and see what is the tiny level we estimate when the most likely time of ingestion was if a patient was alone between again 8 and 11 pm we’re gonna guess that it was at eight we want to imagine
The worst case scenario and then we’ll draw how many hours out and we’ll plot a point the level and how many hours out from when they ingested the drug if the dot is above the line we will treat if the dot is below the line we will not treat different nomograms look slightly different i would urge you to find one and look online you can see how we do it the
Key thing here though is that for an infant who’s been ingesting this over a period of time we can’t use the nomogram this is because this is a the patient over the say the first day of use was using up their glutathione levels now an appropriate dose could cause liver toxicity so the nomogram is only for a one-time overdose more consistent with adolescent so if
You plot them on a nomogram or in infants cases they’re just having bumped lfts and you’re worried about tylenol toxicity we’re going to treat them with iv and acetylcysteine n-acetyl cysteine allows for the degradation of tylenol without needing the glutathione that the patient doesn’t have anymore so we’re going to treat typically for a full course it usually
Lasts around 18 hours and then we will track those tylenol levels and watch them come down so we’ll also get liver enzymes typically after day two because getting them originally at the time of admission to the hospital may lull you into a sense of security remember those lfts don’t typically spike until day two or day three after the ingestion if they are going
Up early transferal to a transplant center is critically important because we need to get those patients on a liver transplant list as soon as we can so let’s switch gears again to another type of overdose which is when patients have overdoses related to their anticholinergic receptors so the cholinergic receptors or the acetylcholine receptors are all through
The body and have different responsibilities typically we see anticholinergic response to overdoses of very particular medications but one of them is very common and that’s benadryl or diphenhydramine sometimes we see patients overdose on diaphone hydramine because it’s commonly what’s in the closet that would be adolescents or children get into it and overdose
We can also see anticholinergic response to patients who overdose on other drugs like tricyclic antidepressants or meds such as glycopyrolite which are used for some patients for drying out the mucous membranes okay the muscarinic receptors are responsible for sweating salivating intestinal motility urinary excretion pupillary constriction and decreased heart
Rate the nicotinic receptors are responsible for the sympathetic ganglia and the neuromuscular junction and the cns receptors are responsible for memory cognition and of course motor coordination so we have to remember that all of these receptors can be affected in an anticholinergic response so there’s a mnemonic for anticholinergic side effects which many of us
Like to use that you’ve probably seen and heard before which is blind is a bat these patients will have dilated pupils remember it’s anticholinergic red is a beet they will have vasodilation in the skin resulting in erythroderma hot as a hair they will be hypothermic dry as a bone they’ll have dry mucous membranes especially in the mouth mad as a hatter they will
Often have mental status changes bloated as a toad they may have urinary attention or intestinal ileus so their abdominal extension may be there and the heart runs alone means they have some tachycardia so if we see that pattern of symptoms that’s a sign that a patient may have overdosed on something like benadryl so what do we do for anticholinergic toxicity
Well again activated charcoal is important if it’s within an hour of ingestion and if it’s a young patient who won’t take the charcoal drop an ng and put it in there for them we can give benzodiazepines for the agitation and in severe cases we may administer physostigmine which is an anticholinerase and could boost the acetylcholine present in the neuromuscular
Junction and in other junctions between nerves
Transcribed from video
Acetaminophen Toxicity in Children – Online Pediatrics Course By dr kaplan
