Reliability of the reported ingested dose of acetaminophen. Single acute acetaminophen overdose nomogram rumack matthew line treatment line treatment should be administered if level is above solid line 36 24 12 16 20 28 32 hours postingestion nomogram. Obtain acetaminophen concentration at 4 hours postingestion or as soon as possible thereafter. When the nac study was begun in 1976 the fda required a line that was 25% below the original line.
Arch single acute acetaminophen overdose nomogram rumack matthew line treatment line treatment should be administered. Using this nomogram, a serum acetaminophen concentration greater than 150 mcgml at 4 hours postingestion indicates that hepatotoxicity is possible. It is important to get an accurate time of ingestion, as the rumack matthew nomogram is entirely dependent on knowing time of ingestion. If negative result hours can not rely on qualitative test. Interactive rumackmatthew nomogram for acetaminophen toxicity estimate toxicity for the single, acute overdose only. Derived from retrospective analysis of apap overdose patients and their clinical outcomes ii. Rumack matthew nomogram to assess the risk of hepatotoxicity 2,8. Acetaminophen paracetamol overdose page 3 of 22 hospital director. The study line which is now referred to as the treatment line was created starting at 150 at 4 hours and is the usual line used in the united states to determine treatment of acetaminophen paracetamol overdose.
The rumack matthew nomogram cannot be used, but likelihood of clinically significant hepatotoxicity can be estimated based on ast, alt, and serum acetaminophen levels. A serum acetaminophen concentration in these patients, taken after 4 hours and before 24 hours postingestion, can be plotted. It is a revision of previous publications and should be used in place of earlier versions. Rumackmatthew nomogram cannot be used to interpret serum apap concentrations in these cases. The rumack matthew nomogram is a tool used to stratify patients at risk for hepatotoxicity after a single acute acetaminophen ingestion 16,17at a known point in time figure. Matthew he has to estimate the whether a plasma in to the should cautions for use of this chart. Guidelines for the management of paracetamol poisoning in. Toxicology case studies acetaminophen and liver function. Treatment threshold levels are calculated to be 25% lower than the toxic drug level. Plot acetaminophen concentration on rumack matthew nomogram see above. This calculator is based on data from rumack and matthew 1. As the article describes, the rumack matthew nomogram, first published in 1975 pediatrics 1975. Acetaminophen levels were obtained 3 hours and 5 hours after ingestion.
Request pdf should the rumackmatthew nomogram be used in pediatric patients. Cooperative adult patients who have potentially ingested. The lower line on the nomogram is the possible line, which was subsequently added later per request of the u. The treatment line of the rumack matthew nomogram is the plasma concentration of acetaminophen above which treatment with nacetylcysteine nac is indicated. Other tests to consider include serum aminotransferase levels, electrolyte and renal function assays, and blood prothrombin time. Fourth, accurate risk assessment requires an accurate time of ingestion, which is not always attainable. Commons is a freely licensed media file repository. Information from its description page there is shown below. Interactive rumackmatthew nomogram for acetaminophen.
Hi everyone, my name is parker vandermeer and i am a third year medical student at the university of alberta. Original nomogram rumack bh matthew h, acetaminophen. Rumack matthew nomogram the rumack matthew nomogram, also known as rumack matthews nomogram or the acetaminophen nomogram is an acetaminophen toxicity nomogram plotting serum concentration of acetaminophen against the time since ingestion in an attempt to prognosticate possible liver toxicity as well as allowing a clinician to decide whether. Rumackmatthew nomogram placement was determined using formulas derived and published by white and rumack. The rumack matthew nomogramalso known as rumack matthews nomogram or the acetaminophen nomogram is an acetaminophen toxicity nomogram plotting serum concentration of acetaminophen against the time since ingestion no,ogram an attempt to prognosticate possible liver toxicity as well as allowing a clinician to decide whether to proceed with n.
Toxic acetaminophen ingestion is often evaluated using the rumack matthew nomogram, which was. Interventions for paracetamol acetaminophen overdose. The nomogram has been developed to estimate the probability of whether a plasma acetaminophen concentration in relation to the interval postinges. The study line which is now referred to as the treatment line was created starting at 150 at 4 hours and is the usual line used in the united states to determine treatment of acetaminophen paracetamol. May 15, 2008 the rumack matthew nomogram uses a serum acetaminophen concentration taken four to 24 hours after first ingestion to determine a patients risk of developing hepatotoxicity after acetaminophen.
Interactive rumack matthew nomogram for acetaminophen toxicity estimate toxicity for the single, acute overdose only. Plotting paracetamol concentration versus time since ingestion, there are various treatment lines and risk lines for developing hepatotoxicity that are utilised to guide treatment. The rumack matthew nomogram the acetaminophen toxicity nomogram or acetaminophen nomogram, is used to interpret serum acetaminophen concentrations in relation to time since ingestion, in order. The rumack matthew nomogram summarizes the relationship between plasma acetaminophen concentration in microgramml or micromolel, the time after drug ingestion, and the. Use of the rumackmatthew nomogram in cases of extended. Gif versions of the rumack matthew and done nomograms for acute acetaminophen and salicylate toxicity. The clinical management of acetaminophen poisoning in a. Lcltarticle multiplying the serum aminotransferase by the. The original line starting at 200 at 4 hours was published in 1975. Chronic ingestion can result in severe toxicity or. Sep 20, 2019 use the rumackmatthew nomogram figure 1 to determine whether or not to initiate treatment with acetylcysteine injection 2.
Acetaminophen poisoning merck manuals professional edition. This calculator is only appropriate for patients who had a single ingestion of acetaminophen. Editorial management of acute paracetamol poisoning. Acetaminophen overdose show notes word format acetaminophen overdose show notes pdf mentioned in the podcast. Arch single acute acetaminophen overdose nomogram rumackmatthew line treatment line treatment should be administered. Pdf recommendations for the paracetamol treatment nomogram. The rumack matthew nomogram for predicting acetaminophen hepatotoxicity. If ast and alt levels are normal rumack matthew nomogram cannot be used to interpret serum apap concentrations in these cases. While the patient awaited psychiatric consultation, the acetaminophen level was measured for the third time 11 hours after ingestion. See rumack matthew nomogram for acetaminophen poisoning. Of 289 cases eligible for placement on the rumack matthew nomogram acute ingestion with known time of ingestion rumack matthew nomogram appendix a i.
About 60% of patients with values above this line develop hepatotoxicity. Cases were analyzed for demographics, timing of acetaminophen concentrations, and application of the rumack matthew nomogram in acetylcysteine initiation or termination. This concentration is plotted on a paracetamol nomogram such as the rumack. Recommendations for the paracetamol treatment nomogram and side effects of nacetylcysteine article pdf available in the netherlands journal of medicine 725. See full prescribing information for instructions on how to use the nomogram to determine the need for dosing. If above treatment line line connecting 150 gml 993 moll at 4 hours and 4. How is the rumackmatthew nomogram used in the workup of. It is important to get an accurate time of ingestion, as the rumackmatthew nomogram is entirely dependent on knowing time of ingestion. Sep 21, 2010 all data were entered directly into a microsoft excel spreadsheet developed a priori for study data entry. Even in the acute overdose, this nomogram is not perfect.
The prescott nomogram was based on a cohort of patients in edinburgh and extends from 200 mgl 20. The rumack matthew nomogram uses the serum acetaminophen concentration, in relation to the time after ingestion, to assess potential. Updated guidelines for the management of paracetamol. Weve been working on a dynamic toxicity nomogram generation routine for both the rumack matthew nomogram for acute acetaminophen toxicity, and the done nomogram for acute salicylate toxicity, both of which are. Rumack matthew nomogram for the single acute acetaminophen poisoning. Start nacetylcysteine nac treatment within 8 hours postingestion to decrease the risk of.
Matthew nomogram, to determine the need for treatment smilkstein 1988. The rumack matthew nomogram is used to interpret the acetaminophen level chart 1. Used to distinguish patients likely to suffer hepatotoxicity iii. Guidelines for the management of acetaminophen overdose. Acep policy on nacetylcysteine for acetaminophen overdose.
Rumack bh, matthew h, acetaminophen poisoning and toxicity. I, the holder of this work, hereby publish it under the following license. Acetaminophen concentrations prior to 4 hours of ingestion. Both values were below the rumack matthew nomogram figure 1. Use the rumack matthew nomogram figure 1 to determine whether or not to initiate treatment with acetadote 2. If positive result hours probable toxic dose, start treatment, draw quantitative level to send to lab, and transport patient to appropriate center. Included herein are flowcharts for managing both acute and chronic acetaminophen. I use this in clinical practice on a daily basis and i will continue to cite and use rumack matthews but that is entirely an insignificant point.
Of 289 cases eligible for placement on the rumack matthew nomogram acute ingestion with known time of ingestion nomogram. Acetaminophen overdose and nac dosing mdcalc nac continues until the paracetamol concentration is undetectable and hepatic transaminases are stable or falling and the patient is clinically improving. Rumack matthew nomogram for single acute acetaminophen ingestions. Acetaminophen level versus time as a method of interpreting levels and assessing severity and need for treatment. The rumack matthew nomogram is the most sensitive risk prediction tool in medical toxicology. Should the rumackmatthew nomogram be used in pediatric. Plot acetaminophen concentration on rumackmatthew nomogram see above. Rumack matthew nomogram to determine when to use nac nac. Acetaminophen overdose in pediatric populations developed by parker vandermeer and dr. Statistical analysis was performed with stata statistical software stata corp. If the initial acetaminophen level plots above the treatment. The rumack matthew nomogram, also known as rumack matthews nomogram or the acetaminophen nomogram is an acetaminophen toxicity nomogram.
If ast and alt levels are normal matthew and rumack but i could not find a direct referrence to exactly rumack matthew nomogram. Use the rumackmatthew nomogram figure 1 to determine whether or not to initiate treatment with acetadote see dosage and administration 2. Original nomogram rumack bh matthew h, acetaminophen pediatrics 1975 55 871 876. This was a retrospective, observational case series at three regional poison centers of acute acetaminophen exposures between 11 and 1231. Based on the plasma level of acetaminophen at a specific time postingestion, the likelihood of hepatic injury.
Acetadote is an antidote for acetaminophen overdose. Duration of intravenous nacetylcysteine in acetaminophen. Until 2012, tis and ntic recommended the treatment according to the rumack matthew nomogram with 150 mgl paracetamol level at 4 hours after ingestion. Chronic ingestion can result in severe toxicity or even death with much lower serum levels. When acute acetaminophen ingestion has been confirmed, the rumack matthew nomogram is the primary treatment guide. Nac figure 2 was approved by the fda in 1985 for oral use 2. Tylenol acetaminophen ingestion california poison control 18008764766 toxicity 1. In this calculator, mcg is the abbreviation for micrograms.