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Sepsis pathway — USMLE Step 3 MCQ

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HardEthics, Patient Safety, Quality Improvement, Systems-Based PracticeSepsis pathwayUSMLE Step 3

A 24-year-old woman presents 18 hours after intentionally ingesting an uncertain amount of extended-release acetaminophen. She has nausea and right upper-quadrant tenderness. AST is 186 U/L, ALT is 204 U/L, INR is 1.4, and the acetaminophen concentration is 18 mcg/mL. The time of ingestion is reliable, and activated charcoal was not given. Which management is most appropriate?

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Correct answer: C — Begin intravenous N-acetylcysteine and follow hepatic tests and acetaminophen concentration

The best answer is “Begin intravenous N-acetylcysteine and follow hepatic tests and acetaminophen concentration”. The nomogram applies to a single immediate-release ingestion with a level drawn 4–24 hours after ingestion, but treatment should not be delayed when presentation is late, the product is extended-release, the dose is uncertain, acetaminophen remains detectable, and hepatic injury is emerging. N-acetylcysteine improves outcomes even after the early window and is continued until clinical and laboratory stopping criteria are met.

Reference: AASLD Position Paper: Acute Liver Failure: https://www.aasld.org/sites/default/files/2022-07/AcuteLiverFailureUpdate201journalformat1.pdf