Acetaminophen citations
Acetaminophen (Panadol, Paracetamol, Calpol, Salzone, Tylenol)

Acetaminophen can cause serious damage to liver cells and tissues when an overdose is taken or it is used in combination with alcohol. In 1996 alone, 74,000 cases of acetaminophen toxicity were reported in the United States, according to United States Poison Control Centers figures.

Yang CC, Deng JF, Lin TJ.  Pancytopenia, hyperglycemia, shock, coma, rhabdomyolysis, and pancreatitis associated with acetaminophen poisoning.Vet Hum Toxicol. 2001 Dec;43(6):344-8.PMID: 11757993 [PubMed - indexed for MEDLINE]
It is well recognized that acetaminophen overdose can cause severe hepatic injury. However, extra-hepatic manifestations may also develop following inappropriate use or ingestion of large amounts of acetaminophen. We present a 44-y-o female who manifested coma, metabolic acidosis, shock, hypothermia, hyperglycemia, rhabdomyolysis, hepatotoxicity, and renal insufficiency after suicidal ingestion of an unknown amount of acetaminophen. Although her consciousness and hemodynamic status gradually improved after treatment with N-acetylcysteine and other supportive measures, she was found to have pancytopenia, pancreatitis and hepatorenal failure during the hospitalization and eventually died 18 d post-admission. Review of relevant literature reports and the clinical findings in our patient suggests that direct toxic effects mediated by acetaminophen or its metabolites were most likely responsible for most of the observed clinical features.

Ranganathan SS, Fernandopulle BM, de Silva MV, Fernandopulle M.Fulminant heptic failure in a child following paracetamol overdosing.Ceylon Med J. 2001 Jun;46(2):72-3. No abstract available.PMID: 11727585 [PubMed - indexed for MEDLINE]

Stevenson R, MacWalter RS, Harmse JD, Wilson E.  Mortality during the winter flu epidemic--two cases of death associated with self-medication.Scott Med J. 2001 Jun;46(3):84-6.PMID: 11501327 [PubMed - indexed for MEDLINE]

We report two cases of mortality associated with the recent winter influenza outbreak. Both cases were associated with self-medication. In one case an elderly lady died from haemorrhagic duodenitis induced by over the counter ibuprofen. In the second case the lady died from the consequences of exceeding the recommended doses of paracetamol by combining doses of the generic product with proprietary flu-remedies and Tylex (paracetamol and codeine).

Nyberg SL, Pfeifer EA. Related Articles
Cerebral edema with herniation during acetaminophen-induced fulminant hepatic failure.
Liver Transpl. 2000 Jul;6(4):495-6. No abstract available.
PMID: 10915174 [PubMed - indexed for MEDLINE]
16: Ayonrinde OT, Saker BM. Related Articles
Anaphylactoid reactions to paracetamol.
Postgrad Med J. 2000 Aug;76(898):501-2.
PMID: 10908380 [PubMed - indexed for MEDLINE]
Roth B, Woo O, Blanc P. Related Articles
Early metabolic acidosis and coma after acetaminophen ingestion.
Ann Emerg Med. 1999 Apr;33(4):452-6.
PMID: 10092726 [PubMed - indexed for MEDLINE]

Metabolic acidosis and coma may develop in patients who experience severe hepatic injury after acetaminophen poisoning. The onset of acidosis and coma soon after acetaminophen overdose, but preceding manifest hepatic injury, contrasts with the typical course of poisoning. This pattern has been reported in a limited number of cases. Coingestions and the rare occurrence of these findings after an overdose have engendered controversy as to whether acetaminophen alone is the cause of early coma and acidosis. We describe 4 separate overdoses among 3 patients who arrived at the emergency department comatose with a metabolic acidosis soon after ingesting large amounts of acetaminophen without evidence of toxic liver injury. Our cases support the view that early metabolic acidosis with coma does indeed occur after acetaminophen poisoning, independent of hepatic failure or its complications.

Davie A. Related Articles
Acetaminophen poisoning and liver function.
N Engl J Med. 1994 Nov 10;331(19):1311; discussion 1311-2. No abstract available.
PMID: 7935695 [PubMed - indexed for MEDLINE]
7: Gilmore IT, Tourvas E. Related Articles
Paracetamol-induced acute pancreatitis.
Br Med J. 1977 Mar 19;1(6063):753-4. No abstract available.
PMID: 851712 [PubMed - indexed for MEDLINE]
8: Osterhout SK. Related Articles
Acetaminophen poisoning.
N C Med J. 1981 Sep;42(9):665-6. No abstract available.
PMID: 6946298 [PubMed - indexed for MEDLINE]
9: Caldarola V, Hassett JM, Hall AH, Bronstein AB, Kulig KW, Rumack BH. Related Articles
Hemorrhagic pancreatitis associated with acetaminophen overdose.
Am J Gastroenterol. 1986 Jul;81(7):579-82.
: Waldron G. Related Articles
Liver failure induced by paracetamol.
BMJ. 1993 Mar 13;306(6879):717-8. No abstract available.
PMID: 8333876 [PubMed - indexed for MEDLINE]
11: Whitcomb DC. Related Articles
Acetaminophen poisoning and liver function.
N Engl J Med. 1994 Nov 10;331(19):1311-2. No abstract available
Koulouris Z, Tierney MG, Jones G. Related Articles
Metabolic acidosis and coma following a severe acetaminophen overdose.
Ann Pharmacother. 1999 Nov;33(11):1191-4.
PMID: 10573319 [PubMed - indexed for MEDLINE]
14: Hamm J. Related Articles
Acute acetaminophen overdose in adolescents and adults.
Crit Care Nurse. 2000 Jun;20(3):69-74. Review. No abstract available.
PMID: 11876216 [PubMed - indexed for MEDLINE]
15: Garnier R. Related Articles
[Acute paracetamol and aspirin poisoning]
Rev Prat. 1997 Apr 1;47(7):736-41. French.
PMID: 9183950 [PubMed - indexed for MEDLINE]
16: Gerrard DF. Related Articles
Renal abuse from non-steroidal, anti-inflammatory agents in sport.
N Z Med J. 1998 Mar 27;111(1062):107-8. No abstract available.
PMID: 9577467 [PubMed - indexed for MEDLINE]
Poulsen HE, Ranek L. Related Articles
[Paracetamol poisoning]
Ugeskr Laeger. 1984 Dec 17;146(51):4030-3. Danish. No abstract available.
PMID: 6523605 [PubMed - indexed for MEDLINE]
18: Evans J. Related Articles
Liver failure induced by paracetamol.
BMJ. 1993 Mar 13;306(6879):717. No abstract available.
PMID: 8329027 [PubMed - indexed for MEDLINE]
19: Wang PH, Yang MJ, Lee WL, Chao HT, Yang ML, Hung JH. Related Articles
Acetaminophen poisoning in late pregnancy. A case report.
J Reprod Med. 1997 Jun;42(6):367-71.
PMID: 9219126 [PubMed - indexed for MEDLINE]
BACKGROUND: Acetaminophen poisoning is a major cause of hospital admission and has been extensively reviewed. Its occurrence in pregnant women has been reported seldom, and the prognosis has been good except for one case, in which the fetus died. We report on a case of acetaminophen poisoning that resulted in the death of both the mother and the infant. CASE: A 38-year-old woman whose pregnancy was at 31 weeks' gestational age was evaluated for treatment of an acetaminophen overdose. She was admitted more than 26 hours after taking 35 g of acetaminophen. An emergency cesarean section was performed one hour after admission because of acute fetal distress. A grossly normal, 1,620-g, female infant was delivered and had Apgar scores at 1, 5 and 10 minutes of 0, 0 and 1, respectively, despite the initiation of resuscitation immediately following delivery. Acidosis was noted in the mother during the operation; it was followed by acute hepatorenal failure 16 hours after admission. That resulted in the mother's death 40 hours after admission. The infant also died 34 hours after delivery. CONCLUSION: Delays in administering the antidote treatment, N-acetylcysteine, after acetaminophen intoxication significantly increase the risk of mortality in both the mother and infant. The development of acidosis carries a poor prognosis in such patients and may necessitate liver transplantation to save the life of the mother.
20: Sellers EM, Freedman F. Related Articles
Treatment of acetaminophen poisoning.
Can Med Assoc J. 1981 Oct 15;125(8):827-9. Review.
PMID: 7030465 [PubMed - indexed for MEDLINE]
21: Larsen FS, Clemmesen JO, Hansen BA. Related Articles
[Hemorrhagic pancreatitis. A rare complication of paracetamol poisoning]
Ugeskr Laeger. 1995 Feb 13;157(7):898-9. Danish. No abstract available.
PMID: 7701652 [PubMed - indexed for MEDLINE]
22: Van Vyve T, Hantson P, Deckers O, Mahieu P. Related Articles
Severe acetaminophen poisoning with favorable outcome after medical treatment: report of 2 cases.
Acta Clin Belg. 1993;48(6):392-6.
PMID: 8128818 [PubMed - indexed for MEDLINE]
23: Bailey BO. Related Articles
Acetaminophen poisoning and its treatment.
Compr Ther. 1982 Dec;8(12):16-21. No abstract available.
PMID: 7160160 [PubMed - indexed for MEDLINE]
24: Baciewicz AM, Sokos DR, King TJ. Related Articles
Acute pancreatitis associated with celecoxib.
Ann Intern Med. 2000 Apr 18;132(8):680. No abstract available.
PMID: 10766698 [PubMed - indexed for MEDLINE]
29: Wall C. Related Articles
The real risk of acetaminophen overdose.
RN. 1985 Aug;48(8):35-7. No abstract available.
PMID: 3849088 [PubMed - indexed for MEDLINE]
30: Sharma SD. Related Articles
Is paracetamol an NSAID?
J Assoc Physicians India. 1991 Sep;39(9):727, 729. No abstract available.
PMID: 1814924 [PubMed - indexed for MEDLINE]
31: Antaki A, Rollin P, Weber M, Chicoine L. Related Articles
[Acetaminophen poisoning]
Union Med Can. 1978 Jul;107(7):670-3. French. No abstract available.
PMID: 664109 [PubMed - indexed for MEDLINE]
33: Maroy B. Related Articles
[Benign acute pancreatitis probably due to taking ketoprofen]
Therapie. 1998 Nov-Dec;53(6):602-3. French. No abstract available.
PMID: 10070244 [PubMed - indexed for MEDLINE]
34: Ranganathan SS, Fernandopulle BM, de Silva MV, Fernandopulle M. Related Articles
Fulminant heptic failure in a child following paracetamol overdosing.
Ceylon Med J. 2001 Jun;46(2):72-3. No abstract available.
PMID: 11727585 [PubMed - indexed for MEDLINE]
35: Delanty N, Fitzgerald DJ. Related Articles
Paracetamol poisoning: the action line and the timing of acetylcysteine therapy.
Ir Med J. 1996 Sep-Oct;89(5):156, 158. Review. No abstract available.
PMID: 8936831 [PubMed - indexed for MEDLINE]
36: Ferguson DR, Synder SK, Cameron AJ. Related Articles
Hepatotoxicity in acetaminophen poisoning.
Mayo Clin Proc. 1977 Apr;52(4):246-8.
PMID: 846223 [PubMed - indexed for MEDLINE]
Nasadi M. Related Articles
Treatment of acetaminophen poisoning.
Can Med Assoc J. 1982 Feb 1;126(3):232. No abstract available.
PMID: 7059898 [PubMed - indexed for MEDLINE]
42: Silverman JJ, Carithers RL Jr. Related Articles
Acetaminophen overdose.
Am J Psychiatry. 1978 Jan;135(1):114-5. No abstract available.
PMID: 618508 [PubMed - indexed for MEDLINE]
43: Hornfeldt CS. Related Articles
Distinction made between toxicoses caused by acetaminophen and nonsteroidal anti-inflammatory drugs.
J Am Vet Med Assoc. 1992 Nov 1;201(9):1318-9. No abstract available.
PMID: 1429174 [PubMed - indexed for MEDLINE]
45: Chan TY. Related Articles
The epidemiology of acetaminophen (paracetamol) poisoning in Hong Kong.
Vet Hum Toxicol. 1996 Dec;38(6):443-4.
PMID: 8948078 [PubMed - indexed for MEDLINE]
46: Jeyaranjan R. Related Articles
When does acetaminophen poisoning require treatment?
Postgrad Med. 1991 Oct;90(5):272. No abstract available.
PMID: 1924013 [PubMed - indexed for MEDLINE]
47: Mathis RD, Walker JS, Kuhns DW. Related Articles
Subacute acetaminophen overdose after incremental dosing.
J Emerg Med. 1988 Jan-Feb;6(1):37-40. Review.
PMID: 3283215 [PubMed - indexed for MEDLINE]

A case of acetaminophen poisoning following the ingestion of 26 g of acetaminophen by incremental dosing over a 25-h period is reported. At presentation, seven h after the last ingestion, the patient experienced hematemesis, the acetaminophen level was 150 micrograms/mL, and the SGOT was normal. The patient recovered uneventfully following N-acetylcysteine therapy. A review of the pharmacology and toxicity of acetaminophen is discussed. The case illustrates the problems of judging hepatotoxic potential in a multiple-dose acetaminophen ingestion and describes the successful use of N-acetylcysteine in a patient with a "subacute" acetaminophen overdose.

: Bailey B, Lalkin A, Kapur BM, Koren G. Related Articles
[Is chronic poisoning with acetaminophen in children a frequent occurrence in Toronto?]
Can J Clin Pharmacol. 2001 Summer;8(2):96-101.
PMID: 11493938 [PubMed - indexed for MEDLINE]

BACKGROUND: Acetaminophen is a common cause of poisoning in children. Recent American studies suggest that acetaminophen poisonings pose serious risks in children, particularly in the case of chronic poisoning caused by therapeutic error. OBJECTIVE: To evaluate whether chronic acetaminophen poisoning in children is a frequent occurrence in a large, Canadian, urban population. PATIENTS AND METHODS: Retrospective study. Charts of all patients admitted to The Hospital for Sick Children, Toronto, Ontario from January 1, 1990 to June 31, 1996 with an acetaminophen overdose were reviewed. RESULTS: A total of 110 patients were admitted within the study period; only four of whom were preschool children (younger than five years of age). Among the preschool children, three had an acute overdose and one had possible chronic poisoning by therapeutic error. All preschool children were treated with N-acetylcysteine; one developed hepatotoxicity (aspartate aminotransferase or alanine aminotransferase greater than 1000 U/L) after presenting 24 h after acute ingestion. Of the remaining patients, all were adolescents; 102 had acute intentional overdose and four had staggered intentional overdoses. Fifty-three adolescents were treated with N-acetyl cysteine. Hepatotoxicity was present in 13 of 63 adolescents (21%). No patients required liver transplantation or died. CONCLUSIONS: Contrary to American experience, chronic acetaminophen poisoning, including therapeutic error in children in Toronto, is a rare occurrence--most cases of acetaminophen poisonings are acute intentional ingestion in adolescents.

54: Ritter A, Eskin B. Related Articles
Ibuprofen overdose presenting with severe agitation and hypothermia.
Am J Emerg Med. 1998 Sep;16(5):549-50. No abstract available.
PMID: 9725984 [PubMed - indexed for MEDLINE]
55: Calvert LJ, Linder CW. Related Articles
Acetaminophen poisoning.
J Fam Pract. 1978 Nov;7(5):953-6.
PMID: 722269 [PubMed - indexed for MEDLINE]
56: Salgia AD, Kosnik SD. Related Articles
When acetaminophen use becomes toxic. Treating acute accidental and intentional overdose.
Postgrad Med. 1999 Apr;105(4):81-4, 87, 90. Review.
PMID: 10223088 [PubMed - indexed for MEDLINE]
57: Schattner A, Sokolovskaya N, Cohen J. Related Articles
Fatal hepatitis and renal failure during treatment with nimesulide.
J Intern Med. 2000 Jan;247(1):153-5.
PMID: 10672143 [PubMed - indexed for MEDLINE]A healthy 70-year-old woman who took nimesulide for 5 days, presented 2 weeks later with jaundice for which no other cause was found. Laboratory evidence of coagulopathy, hypoalbuminaemia and hypoglycaemia were present on admission, and liver biopsy showed massive necrosis of hepatocytes and severe inflammatory infiltrate. Despite supportive and corticosteroid treatment, her jaundice deepened and progressive acute renal failure developed, characterized by a 'prerenal' profile changing into irreversible acute tubular necrosis pattern, coma, occult Gram-negative sepsis and death. Although rare, nimesulide-associated hepatotoxicity and nephrotoxicity may occur and should be recognized as early as possible, to ensure immediate drug withdrawal and treatment.
58: Carloss H, Forrester J, Austin F, Fuson T. Related Articles
Carloss H, Forrester J, Austin F, Fuson T. Related Articles
Acute acetaminophen intoxication.
South Med J. 1978 Aug;71(8):906-8.
PMID: 684469 [PubMed - indexed for MEDLINE]
Acetaminophen is a readily available, widely used drug which has been thought safer than aspirin. Overdosage which may result in fatal hepatic necrosis is commonly seen in the United Kingdom but is rarely reported in the United States. In a two-month period, three patients were admitted to a general hospital because of acetaminophen overdose, suggesting that this problem may occur more commonly than expected. They were successfully treated with N-acetylcysteine. Our experience in management of these three patients is presented and the pertinent literature concerning diagnosis and treatment of acute acetaminophen intoxication in briefly reviewed.
59: [No authors listed] Related Articles
N-acetylcysteine in the treatment of acetaminophen overdose.
N Engl J Med. 1989 May 25;320(21):1417-8. No abstract available.
PMID: 2634982 [PubMed - indexed for MEDLINE]
60: Coward RA. Related Articles
Paracetamol-induced acute pancreatitis.
Br Med J. 1977 Apr 23;1(6068):1086. No abstract available.
PMID: 858062 [PubMed - indexed for MEDLINE]
2: Kritharides L, Fassett R, Singh B. Related Articles
Paracetamol-associated coma, metabolic acidosis, renal and hepatic failure.
Intensive Care Med. 1988;14(4):439-40.
PMID: 3403780 [PubMed - indexed for MEDLINE]
63: Southiere G, Perrone J. Related Articles
Acetaminophen overdose.
Ann Emerg Med. 1995 Jan;25(1):117-8. No abstract available.
PMID: 7802362 [PubMed - indexed for MEDLINE]
64: Walker RJ. Related Articles
Paracetamol, nonsteroidal antiinflammatory drugs and nephrotoxicity.
N Z Med J. 1991 May 8;104(911):182-3. Review. No abstract available.
PMID: 2027607 [PubMed - indexed for MEDLINE]
65: Vale JA, Proudfoot AT. Related Articles
Paracetamol (acetaminophen) poisoning.
Lancet. 1995 Aug 26;346(8974):547-52. Review. No abstract available.
PMID: 7658783 [PubMed - indexed for MEDLINE]
Boberg KM, Schrumpf E, Rogstad B, Berg KJ, Ganes T, Bergan A. Related Articles
[Treatment of paracetamol poisoning. An indication for liver transplantation?]
Tidsskr Nor Laegeforen. 1994 Apr 20;114(10):1199-203. Norwegian.
PMID: 8209319 [PubMed - indexed for MEDLINE]
Development of metabolic acidosis (pH < 7.30) or the combination of encephalopathy grade III-IV, coagulopathy (PT > 100s) and oliguric renal failure are associated with a poor prognosis in paracetamol-induced fulminant liver failure. It is important to administer N-acetylcysteine as soon as possible after the overdose, but N-acetyl-cysteine also seems to improve survival when given 36-80h following ingestion. Liver transplantation has been performed in some patients with paracetamol-induced fulminant liver failure, but convincing evidence that transplantation improves survival in this group of patients is still lacking. We discuss the difficulties met in deciding if and when to perform liver transplantation. Renal failure may develop some days after paracetamol poisoning, even in the absence of severe liver damage, and haemofiltration and haemodialysis may be necessary.
75: Dunn RJ. Related Articles
Massive sulfasalazine and paracetamol ingestion causing acidosis, hyperglycemia, coagulopathy, and methemoglobinemia.
J Toxicol Clin Toxicol. 1998;36(3):239-42.
PMID: 9656981 [PubMed - indexed for MEDLINE]