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Most common management of pcm poisioning

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paracetamol poisoning AND acetylcysteine

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paracetamol poisoning treatment acetylcysteine guidelines

Paracetamol (PCM/acetaminophen) poisoning is most commonly managed with N-acetylcysteine (NAC, acetylcysteine), usually by IV infusion.
Key steps:
  • Assess immediately in an emergency department or contact poison control.
  • Measure a plasma paracetamol level at least 4 hours after a single acute ingestion and plot it on the treatment nomogram.
  • Start NAC promptly if the level is at or above the treatment line, ingestion time is uncertain or staggered, there is evidence of liver injury, or results will be delayed beyond 8 hours after a potentially toxic dose.
  • Check liver tests, INR/PT, renal function, glucose, and acid-base status.
  • Continue NAC and seek specialist/liver-center advice if ALT/AST, INR, creatinine, or clinical status is abnormal.
NAC is most protective when begun within 8 hours, but should still be given later when indicated. A recent systematic review found two-bag NAC regimens can have similar effectiveness with fewer adverse reactions than three-bag regimens, but the exact protocol is hospital-specific (2025 systematic review, PMID 40013897). The UK safety guidance also recommends acetylcysteine based on the treatment nomogram.
If this concerns an actual overdose, do not wait for symptoms. Go to emergency care or call your local poison center now.

What is the standard IV NAC dosing regimen?

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acetaminophen poisoning AND acetylcysteine

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FDA Acetadote prescribing information 150 mg/kg 50 mg/kg 100 mg/kg 21 hour intravenous regimen

Standard 21-hour IV NAC regimen for paracetamol poisoning: total 300 mg/kg IV in 3 sequential infusions:
  1. 150 mg/kg IV over 1 hour
  2. 50 mg/kg IV over 4 hours
  3. 100 mg/kg IV over 16 hours
For a patient weighing 70 kg, this equals:
  • 10.5 g over 1 hour
  • 3.5 g over 4 hours
  • 7 g over 16 hours
This is the traditional FDA-labeled 3-bag regimen. Infusion volumes must be adjusted for children, low body weight, and fluid-restricted patients to avoid hyponatremia/fluid overload. The FDA product label specifies this 300 mg/kg, 21-hour schedule.
Some hospitals use a 2-bag, 20-hour regimen or the 12-hour SNAP regimen, so use local toxicology guidance. If liver tests, INR, paracetamol level, or clinical status remain abnormal near completion, NAC is usually continued under toxicology or liver-specialist advice.
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