Delays in administration of acetylcysteine in paracetamol overdose

Despite an effective antidote, paracetamol overdose is a frequent cause of fulminant hepatic failure in Ireland and the United Kingdom. Most treatment failures are due to late presentation but some may be related to delayed treatment in hospital. The aim of this study was to investigate delays in treatment in patients presenting to two large Dublin accident and emergency departments. One hundred and seventy seven admissions were recorded over a two year period. The average patient presented 6-8 hours after the overdose and waited another 1.5 to 2 hours for treatment to commence. Treatment was delayed more than 2 hours after presentation in 24/110 (22%) and more than 4 hours in 10/110 (10%). The majority had no adverse sequelae but four patients required ventilation, one haemofiltration and one died. The patient who died presented 35 hours after overdose. This study suggests that delays in treatment of paracetamol overdose are common. Delays of this magnitude may be clinically important in the small minority of patients with significant liver injury. It is possible that oral administration of n-acetylcysteine may reduce delays in treatment.