Blood will be drawn for baseline levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, blood sugar, serum urea nitrogen (BUN), serum creatinine, electrolytes and prothrombin time to monitor hepatic and renal function and electrolyte-fluid balance. An initial acetaminophen concentration would be drawn four hours after ingestion to accurately measure potential hepatotoxicity. These tests would then be drawn at least daily to serve as a basis for determining the need for continuing maintenance doses of acetylcysteine and for other treatments.

ALT, AST, bilirubin and the prothrombin time may be abnormal when there is liver damage. ALT is an enzyme produced in hepatocytes. Even though only a liver biopsy accurately indicates the degree of liver damage, an increase in ALT roughly correlates with the degree of damaged hepatocytes.

AST, an enzyme similar to ALT, is produced in the liver and also in muscle tissue. ALT can be elevated in other conditions than liver damage, such as in myocardial infarction. Bilirubin is a product that results when old blood cells are broken down. It is removed from the blood by the liver, conjugated, and then secreted into the bile. Indirect bilirubin is increased in cases of increased production, decreased uptake, or decreased conjugation by the liver. Direct bilirubin is increased when there is decreased secretion by the liver, or a bile duct obstruction. The prothrombin time (PT) is one type of blood clotting test and is prolonged when some of the clotting factors created by the liver are low. Blood sugars are obtained because the liver helps maintain a proper level of glucose in the blood. BUN levels indicate the amount of urea, which is a waste product of protein metabolism, that is being manufactured by the liver. Severe liver failure causes a reduction of urea in the blood.

Creatinine levels are obtained to ascertain how well the kidneys are functioning. Acute renal failure that occurs with liver disease is referred to as Hepatorenal syndrome (HRS). HRS is usually indicative of an end-stage of perfusion to the kidney due to a deteriorating liver.

While taking the report on Amanda, you were informed that, except for her serum acetaminophen concentration, her blood test results were all within normal limits. Four hours after ingestion, Amanda's blood acetaminophen concentration was 100 ug/mL, which is below hepatotoxicity on an acetaminophen toxicity nomogram. Acetaminophen overdose patients can be cared for on a Medical/Surgical floor unless there are obvious signs of liver damage.

Amanda has just arrived on your floor and while assisting her to bed you notice black smudges around her mouth and on her hands. In your report you were informed that Amanda did not receive syrup of ipecac to induce emesis. She had been lavaged, received activated charcoal, lavaged again and was given her initial dose of acetylcysteine.

Nausea, vomiting and other gastrointestinal symptoms may occur in the large doses of acetylcysteine needed to treat an acetaminophen overdose. Your patient may also develop a rash, with or without fever, from taking acetylcysteine.

Observe acetaminophen overdose patients for mental status changes or clinical signs of encephalopathy. Cerebral edema (which would be detected by a CT scan of the head) can occur in the late stages of an acetaminophen overdose.

Your patient's PT can be prolonged with hepatic injury. Continuously assess your patient for signs of coagulopathy such as bleeding gums, skin bruising and GI bleeding. Vitamin K or fresh frozen plasma may be a necessary treatment.

Since the liver helps maintain blood glucose levels, routine finger stick testing of blood sugar may be ordered.

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