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Calello MD Department of Pediatrics and Emergency Medicine Robert Wood Johnson Medical School UMDNJ Staff Toxicologist, NJ Poison Education and Information Systems Case An 18 year old female presents to the Emergency Department 2 hours after the ingestion of 75 acetaminophen (APAP) 500 mg tablets She has mild abdominal cramping A 4 hour acetaminophen level is 180mcg/mL Case A 27 year old male presents to the Emergency Department with emesis, jaundice and altered mental status He has recently been depressed Two empty bottles of APAP were found in his bedroom There is no further history available Case A 28 year old male, with a PMH for hepatitis C and alcohol abuse, presents to the ED with RUQ pain and emesis He has been taking supratherapeutic doses of APAP His AST and ALT are 360 u/L and 489 u/L respectively APAP level is 45mcg/mL Objectives Understand basic pharmacology, metabolism, and mechanism of acetaminophen toxicity Describe the clinical features associated with APAP toxicity Discuss the principles of treatment: Rationale Indications Timing Frequency of use Most commonly used analgesic Present in hundreds of OTC preparations Over 10,000 calls/year to poison centers Most common annual cause of: pharmaceutical poisoning pharmaceutical poisoning death acute liver failure in US Pharmacology Analgesic, antipyretic with weak anti-inflammatory properties Analgesia at serum APAP concentration of 10mcg/mL Central inhibition of COX-2 and prostaglandin synthase Antipyresis at 4-18mcg/mL CNS inhibition of PGE2 Dosing Therapeutic: Pediatric: 15 mg/kg every 4 hours

For example: The enzyme in the energy production process will transform the digested or absorbed nutrients into energy

Yes, it is standard best practice in any research protocol involving injections to rotate sites

Nature 619 , 585594 (2023)

G., & Della Ma Plentz, R