Paracetamol overdose with hepatic failure — FFICM MCQ

Correct answer: C — Continue acetylcysteine and discuss urgently with a liver transplant centre

The correct answer is C, continue acetylcysteine and discuss urgently with a liver transplant centre. This patient has established paracetamol-induced acute liver failure: markedly raised ALT, coagulopathy (INR 3.4), acidaemia (pH 7.28) and hyperlactataemia (4.9 mmol/L) despite fluid resuscitation, features that meet recognised King's College Hospital criteria for super-urgent transplant referral. In staggered overdose the treatment nomogram cannot be applied since ingestion timing and dose are uncertain, so acetylcysteine must continue (often as an extended infusion) whenever paracetamol is detectable or hepatotoxicity is evident. Persistent acidosis after adequate resuscitation and a climbing INR are red flags for imminent hepatic failure, mandating early hepatology and transplant team involvement before encephalopathy or renal failure develop. Referring while the patient is still transportable is prognostically critical. Why the other options are wrong: A, stop acetylcysteine because 16 hours have elapsed: acetylcysteine should never be withdrawn in the presence of ongoing hepatotoxicity or detectable paracetamol, and staggered overdoses require continued or extended infusion regardless of elapsed time. B, give activated charcoal as sole therapy: charcoal only benefits patients within 1 hour of a single acute ingestion and has no role 18 hours after a staggered overdose with established liver injury. D, wait for jaundice before referral: jaundice is a late sign; delaying referral until it appears would miss the window for transfer before irreversible multiorgan failure supervenes. E, treat with flumazenil: flumazenil reverses benzodiazepine sedation and has no role in paracetamol toxicity, and there is no evidence of benzodiazepine co-ingestion here. Key point: persistent acidosis, rising INR and hyperlactataemia after resuscitation in paracetamol-induced liver injury mandate continued acetylcysteine plus immediate liver transplant centre discussion, not withdrawal of treatment or delay pending deterioration.

Reference: BJA Education (Royal College of Anaesthetists), 'Management of acute liver failure in intensive care', 2021: referral thresholds include INR >3.0 or rising, persistent pH <7.35, hyperlactataemia despite resuscitation, and hepatic encephalopathy warranting early transplant centre discussion. https://www.bjaed.org/article/S2058-5349(20)30156-6/fulltext