Be Vigilant About Acetaminophen (Tylenol) Toxicity
Acetaminophen (Tylenol), one of the most popular medications in the world, is used for the treatment of pain and fever. However, acetaminophen toxicity can lead to acute hepatic failure and the possible need for liver transplantation. The purpose of this article is to discuss acetaminophen toxicity.
Acetaminophen, a medication used for the relief of pain and fever, is a common staple in medicine cabinets around the world and can be found in both over-the-counter (OTC) and prescription formulations. Outside of North America, acetaminophen is better known by the name paracetamol. Even though the brand Tylenol is the most popular acetaminophen-containing product, more than 200 other medications also contain this drug.
When taken at recommended doses, acetaminophen is usually safe and effective. However, this medication can be deadly when too much is taken. In fact, acetaminophen toxicity is the leading cause of acute hepatic failure in the industrialized world. Acetaminophen toxicity is the most common cause of hepatic failure requiring liver transplantation in Great Britain (Farrell, 2012). The majority of overdoses in the US, the UK, Australia, and New Zealand involve acetaminophen. In the United States, APAP toxicity has replaced viral hepatitis as the most common cause of acute hepatic failure and is the second most common cause of liver failure requiring transplantation (Farrell, 2012).
The signs and symptoms of acetaminophen toxicity are experienced by patients in three distinct stages. Many patients display no signs or symptoms of acetaminophen toxicity during the first phase, which is the initial 12 to 24 hours after the overdose. Some patients will experience general complaints such as malaise, nausea, vomiting, mild abdominal pain, and perspiration within a few hours after the overdose. For the next perhaps 12 to 24 hours, which is the second phase or the so-called inactive (latent) phase, the patient feels well (Lee, 2007).
During the third phase, which starts between 48 to 72 hours after the overdose, abnormal hepatic blood levels can be detected. Patients may continue to experience nausea and vomiting while beginning to experience right upper quadrant pain. Hepatic necrosis and dysfunction are associated with jaundice, coagulopathy, hypoglycemia, and hepatic encephalopathy (Farrell, 2012). Acute kidney failure sometimes develops during this third stage; in addition, some patients develop multiple organ failure and die.
For the average healthy adult, the recommended maximum dose of acetaminophen over a 24 hour period is four grams (4000 mg) or eight extra-strength pills (Lee, 2007). However, the patient who consumes more than two alcoholic beverages per day should not take more than two grams of acetaminophen in a 24-hour period. Any patient who has overdosed on acetaminophen must obtain prompt medical attention because interventions are most effective within the first eight hours after the last ingestion.
In addition, a Boxed Warning highlighting the potential for severe liver injury and a Warning highlighting the potential for allergic reactions (e.g., swelling of the face, mouth, and throat, difficulty breathing, itching, or rash) are being added to the label of all prescription drug products that contain acetaminophen (FDA, 2011).
Be sure to inform your patients that many OTC products contain acetaminophen, and reinforce to them that it may appear on the label as 'APAP.' Many patients are unknowingly taking multiple medications that contain acetaminophen, which can be dangerous. If we arm them with this knowledge, they can take the steps necessary to stay safe and prevent harm caused by overdose. Knowledge is power!Last edit by Joe V on Jul 20, '12
About TheCommuter, BSN, RN Senior Moderator
TheCommuter is a moderator of allnurses.com and has varied workplace experiences upon which to draw for her articles. She was an LPN/LVN for four years prior to earning RN licensure.
TheCommuter has '10' year(s) of experience and specializes in 'Case mgmt., rehab, (CRRN), LTC & psych'. From 'Fort Worth, Texas, USA'; 35 Years Old; Joined Feb '05; Posts: 36,123; Likes: 64,299.Jul 20, '12 by Hygiene Queen, RN GuideI don't know why, but I find acetaminophen OD to be a fascinating subject.
I was just talking to my kids about this yesterday and was doing some research for myself.
I have frequent contact with pts (young girls, usually) who choose Tylenol as a suicide method.
The ones I see are the ones that were lucky.
There was one, however, who OD'ed on Tylenol, got a liver transplant... and did it to herself again!
Obviously, no new liver the second time around.
And in spite of recent publicity about acetaminophen and safe doses, people still continue to view it as harmless and take too much...
Teens try to OD on it as a cry for help not realizing that after the window of opportunity is closed, nothing will save them.
What a rotten way to go.
My good friend knows a man who found his brother after a suicide attempt with Tylenol.
It took this poor kid a week or so to die.
He regretted what he had done-- didn't want to die after all...
Nothing to do but wait and die.
Dear god.Jul 20, '12 by TheCommuter, BSN, RN Senior ModeratorQuote from Hygiene QueenMy mother received a liver transplant ten years ago. My mother's health problems had nothing to do with acetaminophen toxicity, but my point is that livers and other organs are precious commodities. If a person who has been given a second chance at life purposely destroys the organ they've been gifted with, I strongly feel that they should not continue to receive more organs.There was one, however, who OD'ed on Tylenol, got a liver transplant... and did it to herself again! Obviously, no new liver the second time around.
Quote from Hygiene QueenI think it is because acetaminophen is a household staple in virtually everyone's medicine cabinet. People view it as safe, comforting, familiar, and trusted. It is totally safe if used as directed, but can be lethal if misused.And in spite of recent publicity about acetaminophen and safe doses, people still continue to view it as harmless and take too much...
Quote from Hygiene QueenThis is so sad. The young man must have realized he made a mistake while he was slowly dying, but probably felt so hopeless at not being able to turn back the hands of time.My good friend knows a man who found his brother after a suicide attempt with Tylenol. It took this poor kid a week or so to die. He regretted what he had done-- didn't want to die after all... Nothing to do but wait and die. Dear god.Jul 20, '12 by Esme12, ASN, BSN, RN Senior ModeratorThere are plenty of unintentional overdoses. People take Tylenol then Nyquil or some other cold preparation and before they know it they have toxic livers. Children are particularly susceptible to this phenomenon. Tylenpl is a toxic drug.Jul 20, '12 by Liddle NoodnikI hope it does not get considered so "lethal" that they do away with it, I depend on it daily for my chronic neck and other aches and pains. Nice job commuter!Jul 20, '12 by buytheshoes11, MSN, RNThank you for this article! I think it is important that we ensure not only our patients are educated, but our coworkers as well. Too often I have heard "Oh it's just two tylenol, he/she will be okay," when in actuality, this person may not be.Jul 20, '12 by NicuGal, MSN, RNWhen I was having a lot of issues with my gallbladder, they did an ultrasound and found one of the lobes of my liver to have the beginnings of fatty liver disease (non-alcoholic). I lead a pretty healthy life style, eat right, etc. They doc asked me if I used a lot of tylenol and NSAIDs and I said I think I use a moderate amount due to aches pains, etc. They told me to stop taking them as this can contribute to this. She said nurses are many times more likely to use the high end of the dosage since we know what it is....guilty. So, to save my liver I have learned to live without Tylenol and Motrin for most things and if I really need it I make sure to take the lowest dose possible. And the effects of these meds can be accumlative over time! My last ultrasound shows improvement, so hopefully my liver can regenerate what it needs too! So be careful!!!Jul 21, '12 by Tragically HipThe problem is that an effective dose is so close to a toxic dose (even more so in children), and so many products have acetaminophen as an ingredient that, depending on what the patient is taking, it's not difficult to unknowingly ingest a dangerously high dosage. A physician had better know whether a patient has a liver disease before prescribing an acetaminophen-containing agent.Jul 21, '12 by BrandonLPN, LPNI'm always a little disturbed by how many nurses (both LPNs and RNs) who don't seem to realize there are lots of drugs contain Tylenol in them. I don't know how many times I see residents on scheduled ATC norco and nurses give liberal doses of PRN Tylenol or ultracet on top of
it. Are they counting how many gms they are getting in 24hrs?
I got in a big fight with my RN supervisor over this issue. I had a res with a temp who I had just given two norco 5/325. She insisted I give him 650mg Tylenol on top. I explained I already did.... In the scheduled norco. She said it didn't count because standing protocol says Tylenol, not norco. Sometimes nurses get too obsessed with facility policy....Jul 21, '12 by PacoUSA, BSN, RNI stopped taking Tylenol a while back just for this reason alone, even though I knew I was far from ever taking enough to become toxic. There have been times during the winter when I get a cold and take Nyquil when I remember that it also contains APAP. For headaches and such, I now take naproxen which seems to work better for me anyway. Not sure however if naproxen has its own insidious evil thoughJul 21, '12 by morteHoly moly, did that super get her lic out of a cracker jack box??Quote from BrandonLPNI'm always a little disturbed by how many nurses (both LPNs and RNs) who don't seem to realize there are lots of drugs contain Tylenol in them. I don't know how many times I see residents on scheduled ATC norco and nurses give liberal doses of PRN Tylenol or ultracet on top of
it. Are they counting how many gms they are getting in 24hrs?
I got in a big fight with my RN supervisor over this issue. I had a res with a temp who I had just given two norco 5/325. She insisted I give him 650mg Tylenol on top. I explained I already did.... In the scheduled norco. She said it didn't count because standing protocol says Tylenol, not norco. Sometimes nurses get too obsessed with facility policy....Jul 21, '12 by BrandonLPN, LPNQuote from morteShe was a CNA who worked for the facility, then she got her RN and went straight to the 3-11 house supervisor position. A position that's all staffing and administrative duties. No actual bedside nursing in-between.Holy moly, did that super get her lic out of a cracker jack box??Jul 21, '12 by Hygiene Queen, RN GuideQuote from BrandonLPNIt sounds like she has no common sense and apparently did not learn anything in school.She was a CNA who worked for the facility, then she got her RN and went straight to the 3-11 house supervisor position. A position that's all staffing and administrative duties. No actual bedside nursing in-between.
Tylenol, if not aspirin, is the first drug you learn about d/t it being so common.
Way to go (!!) for your facility for setting the Peter Principle in motion ASAP!
Last edit by Hygiene Queen on Jul 21, '12
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