Liver Failure in Toxicology
AGENTS
- paracetamol
- iron
- idiosyncratic
- illicit and herbal
- alcohol
CLINICAL FEATURES
- asymptomatic
- nausea and vomiting
- RUQ pain
- jaundice
- coagulopathy
- hypoglycaemia
ENCEPHALOPATHY
- sleep disturbance
- asterixis
- hyper-reflexic
- can be hemiplegic
- precipitating factor: GIH, infection, hypokalaemia, sedatives, increased protein intake, progressive hepatic dysfunction, renal failure
- types: A = acute liver failure, B = presence of portocaval shunting, C = in context of cirrhosis
- grade I -> IV: mildly drowsible but rousable and coherent -> responding to pain/unconscious
INVESTIGATIONS
- level as indicated
-> paracetamol: Rumack-Matthews nomogram @ 4 hours or within 8 hours of OD
-> iron level: > 90 micromoles/L (children), > 145 micromoles/L (adults) within 4 hours of ingestion. - LFT’s
- coagulation
- glucose
- renal function
SPECIFIC MANAGEMENT AND TRIGGERS FOR INTERVENTION
- early discussion with liver transplant unit
- attempt not to reverse coagulopathy until discussion unless actively bleeding
- avoid renal and hepatotoxic agents
Paracetamol
- decrease absorption: activated charcoal if presented within 4 hours (controversial as if NAC given then this is a benign OD)
- vitamin K IV
- N-acetyl cystine in D5W (based on 4 hour level or empirically if > 8 hours since OD):
-> 150mg/kg LD
-> 50mg/kg over 4 hours
-> 100mg/kg over 16 hours
Iron
- gastric lavage with large bore tube (2gm of desferrioxamine in 1L warm water -> leave 10g in 50mL in stomach to chelate any remaining iron)
- IV or IM desferrioxamine (1gm loading dose -> 500mg Q4 hrly depending on severity – maximum = 6g in 24 hrs)
- desferrioxamine -> binds Fe2+ to form water soluble ferrioxamine that is renally excreted
- can use HCO3- (controversial)
- whole bowel irrigation with polyethylene glycol
- gastric lavage
- laparotomy or endoscopic tablet removal (if tablets seen on plain XR)
- exchange transfusion with plasmapheresis
- dialysis – limited efficacy
References and Links
CCC Toxicology Series
General
Approach to acute poisoning, ECGs in Tox, Evidenced-based Tox, Toxicology literature summaries, Does anti-venom work?
Toxins / Overdose
Amphetamines, Barbituates, Benzylpiperazine, Beta Blockers, Calcium Channel Blocker, Carbamazepine, Carbon Monoxide, Ciguatera, Citrate, Clenbuterol, Cocaine, Corrosive ingestion, Cyanide, Digoxin, Ethanol, Ethylene Glycol, Iron, Isoniazid, Lithium, Local anaesthetic, Methanol, Monoamine oxidase inhibitor (MAOI), Mushrooms (non-hallucinogenic), Opioids, Organophosphate, Paracetamol, Paraquat, Plants, Polonium, Salicylate, Scombroid, Sodium channel blockers, Sodium valproate, Theophylline, Toxic alcohols, Tricyclic antidepressants (TCA)
Envenomation
Marine, Snakebite, Spider, Tick paralysis
Syndromes
Alcohol withdrawal, Anticholinergic syndrome, Cholinergic syndrome, Drug withdrawals in ICU, Hyperthermia associated toxidromes, Malignant hyperthermia (MH), Neuroleptic malignant syndrome (NMS), Opioid withdrawal, Propofol Infusion Syndrome (PrIS) Sedative toxidrome, Serotonin syndrome, Sympatholytic toxidrome, Sympathomimetic toxidrome
Decontamination
Activated Charcoal, Gastric lavage, GI Decontamination
Enhanced Elimination
Enhanced elimination, Hyperbaric therapy for CO
Antidotes
Antidote summary, Digibind, Glucagon, Flumazenil, HIET – High dose euglycaemic therapy, Intralipid, Methylene Blue, N-Acetylcysteine (NAC), Naloxone
Miscellaneous
Cocaine chest pain, Digoxin and stone heart theory, Hyperbaric oxygen, Hypoxaemia in tox, Liver failure in tox, Liver transplant for paracetamol, Methaemoglobinaemia, Urine drug screen
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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