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Management of acute paracetamol (acetaminophen) toxicity: a standardised proforma improves risk assessment and overall risk stratification by emergency medicine doctors
  1. David J McQuade1,2,
  2. Srikanth Aknuri3,
  3. Paul I Dargan2,4,5,
  4. David M Wood2,4,5
  1. 1Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
  2. 2Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
  3. 3Clinical Pharmacology, St George's, University of London, London, UK
  4. 4King's Health Partners, London, UK
  5. 5King's College London, London, UK
  1. Correspondence to Dr David M Wood, Medical Toxicology Office, 2nd Floor, Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK; david.wood{at}


Background Paracetamol (acetaminophen) poisoning is the most common toxicological presentation in the UK. Doctors managing patients with paracetamol poisoning need to assess the risk of their patient developing hepatotoxicity before determining appropriate treatment. Patients deemed to be at ‘high risk’ of hepatotoxicity have lower treatment thresholds than those deemed to be at ‘normal risk’. Errors in this process can lead to harmful or potentially fatal under or over treatment.

Aim To determine how well treating doctors assess risk factor status and whether a standardised proforma is useful in the risk stratification process.

Methods Retrospective 12-month case note review of all patients presenting with paracetamol poisoning to our large inner-city emergency department. Data were collected on the documentation of risk factors, the presence of a local hospital proforma and treatment outcomes.

Results 249 presentations were analysed and only 59 (23.7%) had full documentation of all the risk factors required to make a complete risk assessment. 56 of the 59 (94.9%) had the local hospital proforma included in the notes; the remaining 3 (5.1%) had full documentation of risk factors despite the absence of a proforma. A local hospital proforma was more likely to be included in the emergency department notes in those with ‘adequate documentation’ (78 out of 120 (65%)) than for those with ‘inadequate documentation’ (16 out of 129 (12.4%)); X2, p<0.001.

Conclusions Despite a low overall uptake of the proforma, use of a standardised proforma significantly increased the likelihood of documentation of the risk factors which increase risk for hepatotoxicity following paracetamol poisoning.

  • Paracetamol
  • acetaminophen
  • toxicity
  • risk assessment
  • toxicology
  • acute medicine-other

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  • Funding DMW and PID have received a research grant from McNeill Pharmaceuticals for research into the home storage of paracetamol in the UK; PID has acted as an expert adviser to the US Food and Drug Administration on paracetamol poisoning.

  • Competing interests None.

  • Ethics approval Collection of data on our dedicated clinical toxicology database was reviewed and approved by the Caldicott Guardian.

  • Provenance and peer review Not commissioned; externally peer reviewed.