A 22-year-old patient arrives in the emergency department 45 minutes after intentionally ingesting about 12 g of acetaminophen tablets. The patient is awake, able to protect the airway, and has stable vital signs. Which pharmacologic intervention should be performed first to limit further toxicity?
Because the patient presents within 1 hour of a large, acute acetaminophen ingestion and is able to protect the airway, the priority is gastrointestinal decontamination with a single dose of activated charcoal (1 g/kg, up to 50 g). Activated charcoal rapidly adsorbs acetaminophen that remains in the gastrointestinal tract, decreasing systemic absorption and subsequent hepatotoxicity. After charcoal is given, serum acetaminophen levels are obtained at 4 hours, and N-acetylcysteine is started based on the Rumack-Matthew nomogram or empirically if presentation is ≥8 hours or the level is unknown. Intravenous fluids provide supportive care but do not reduce drug absorption, and gastric lavage offers no additional benefit and carries greater risk than charcoal.
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