Based on the plasma level of acetaminophen at a specific time postingestion, the likelihood of hepatic injury. Guidelines for the management of acetaminophen overdose. The rumackmatthew nomogram is used to interpret the acetaminophen level chart 1. Interactive rumackmatthew nomogram for acetaminophen toxicity estimate toxicity for the single, acute overdose only. Acetylcysteine treatment is started if the acetaminophen level falls on or above the line. If the initial acetaminophen level plots above the treatment. Rumack bh, matthew h, acetaminophen poisoning and toxicity.
Acetaminophen levels were obtained 3 hours and 5 hours after ingestion. The nomogram is not applicable in the following circumstances. Solutions for acetaminophen toxicity based on the rumackmatthew nomogram article pdf available in annals of emergency medicine 455. The rumackmatthew nomogram, also known as rumackmatthews nomogram or the.
Once the 4hour acetaminophen level is obtained, it should be plotted against the time since ingestion on the rumackmatthew nomogram. The rumackmatthew nomogram is currently considered the mainstay of risk assessment in acute acetaminophen toxicity cases. About 60% of patients with values above this line develop hepatotoxicity. Plot acetaminophen concentration on rumack matthew nomogram see above. The original and primary source of the name rumack matthew nomogram is taken from the first publication of the nomogram in 1975. Arch single acute acetaminophen overdose nomogram rumack matthew line treatment line treatment should be administered. Single acute acetaminophen overdose nomogram rumackmatthew line treatment line treatment should be administered if level is above solid line 36 24 12 16 20 28 32 hours postingestion nomogram. Acetaminophen nomogram pdf the rumackmatthew nomogram the acetaminophen toxicity nomogram or acetaminophen nomogram, is used to interpret serum. The rumackmatthew nomogram cannot be used, but likelihood of clinically significant hepatotoxicity can be estimated based on ast, alt, and serum acetaminophen levels.
Serum concentration peaks 6090 minutes after ingestion delayed in overdose or longacting form. How is the rumackmatthew nomogram used in the workup of. 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. Halflife is 23 hours at standard doses in a patient with normal renal function. Acetaminophen toxicity in children american academy of. Serum paracetamol concentrations between 4 and 15 h postingestion were compared with the rumackmatthew 200line nomogram, and hepatotoxicity was defined by prothrombin time ratio 1. If above treatment line line connecting 150 gml 993 moll at 4 hours and 4. Both values were below the rumackmatthew nomogram figure 1. The rumackmatthew nomogram is a proven highly sensitive tool to determine patients at risk and requiring treatment. The rumackmatthew nomogram, also known as rumackmatthews 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 to proceed with nacetylcysteine nac treatment or not. As the article describes, the rumackmatthew nomogram, first published in 1975 pediatrics 1975. The correct reference is to that original article which is referenced as number 3. Interactive rumackmatthew nomogram for acetaminophen. The upper line of the nomogram is the probable line, also known as the rumackmatthew line.
Matthew he has to estimate the whether a plasma in to the should cautions for use of this chart. 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 to proceed with nacetylcysteine nac treatment or not. Chronic ingestion can result in severe toxicity or even death with much lower serum levels. Acetaminophen poisoning merck manuals professional edition.
Weve been working on a dynamic toxicity nomogramgeneration routine for both the rumackmatthew nomogram for acute acetaminophen toxicity, and the done nomogram for acute salicylate toxicity, both of which are now online. Rumackmatthew nomogram external link opens in a new window if the plot falls on or above the treatment line, the patient should be treated with acetylcysteine. Acetaminophen overdose diagnostic approach epocrates online. Of 289 cases eligible for placement on the rumack matthew nomogram acute ingestion with known time of ingestion rumackmatthew nomogram for acetaminophen toxicity estimate toxicity for the single, acute overdose only.
The modified rumackmatthew nomogram should only be used in patients with one timepoint apap ingestion. The rumackmatthew nomogram is useful for determining the need for acetylcysteine, if an acute overdose of apap is known to have occurred within the previous 24 hours. Some authors have incorrectly added an s to matthew. When the nac study was begun in 1976 the fda required a line that was 25% below the original line. Using this nomogram, a serum acetaminophen concentration greater than 150 mcgml at 4 hours postingestion indicates that hepatotoxicity is possible. Acetaminophen nomogram contact your local laboratory for hours of service or visit myhealth. Gif versions of the rumackmatthew and done nomograms for acute acetaminophen and salicylate toxicity. The rumackmatthew nomogram, also known as rumackmatthews nomogram or the acetaminophen nomogram is an. The rumackmatthew nomogram the acetaminophen toxicity nomogram or acetaminophen nomogram, is used to interpret serum acetaminophen concentrations in relation to time since ingestion, in order.
The rumackmatthew nomogram uses the serum acetaminophen concentration, in relation to the time after ingestion, to assess potential. The lower line on the nomogram is the possible line, which was subsequently added later per request of the u. Subjects with a serum apap level above the line are at risk for developing hepatotoxicity and should be hospitalized and given nac for a minimum of 24 hours. The rumack matthew nomogram is used to interpret the acetaminophen level chart 1. Plot acetaminophen concentration on rumackmatthew nomogram see above. Benign metabolites are renally excreted after conjugation only 5% is renally excreted unchanged. Patients with serum acetaminophen concentrations that fall above the treatment line following an acute overdose are. While the patient awaited psychiatric consultation, the acetaminophen level was measured for the third time 11 hours after ingestion. Arch single acute acetaminophen overdose nomogram rumackmatthew line treatment line treatment should be administered. The original line starting at 200 at 4 hours was published in 1975. Pdf on jun 1, 2005, steven j white and others published the acetaminophen.
Original nomogram rumack bh matthew h, acetaminophen. Use of the rumackmatthew nomogram in cases of extended. Figure 1 modified rumackmatthew nomogram in apap overdose. If the acetaminophen level is clearly in the toxic range ie, above the treatment line on the rumackmatthew nomogram, dosing with acetylcysteine should be. The rumackmatthew nomogram uses the serum acetaminophen concentration. Other tests to consider include serum aminotransferase levels, electrolyte and renal function assays, and blood prothrombin time. Guidelines for the management of acetaminophen overdose pdf. Original nomogram rumack bh matthew h, acetaminophen pediatrics 1975 55 871 876.
Does the patient history predict hepatotoxicity after. If ast and alt levels are normal acetaminophen ingestion california poison control 18008764766 toxicity 1. It is 25% more conservative than the nomogram as originally developed. Obtain acetaminophen concentration at 4 hours postingestion or as soon as possible thereafter. The rumackmatthew nomogram the acetaminophen toxicity nomogram or acetaminophen nomogram, is used to interpret serum. Treatment may include the administration of acetylcysteine. As there are no early symptoms that predict acetaminophen toxicity, poisoning severity following an acute ingestion is quantified by plotting a timed serum acetaminophen concentration on the modified rumackmatthew nomogram.
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