# Situation: A nurse works in the pediatric emergency room and the pediatric oncology ward of a government hospital. A 3-year-old weighing 14 kg is brought in 1 hour after drinking from a bottle of paracetamol (acetaminophen) syrup, 250 mg/5 mL. The 60-mL bottle was full before the child found it, and 12 mL remain. The child vomited once and is now playful. The hospital uses a toxic-risk threshold of 150 mg/kg. What is the estimated dose ingested? Round off to the nearest whole number.

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse works in the pediatric emergency room and the pediatric oncology ward of a government hospital.

A 3-year-old weighing 14 kg is brought in 1 hour after drinking from a bottle of paracetamol (acetaminophen) syrup, 250 mg/5 mL. The 60-mL bottle was full before the child found it, and 12 mL remain. The child vomited once and is now playful. The hospital uses a toxic-risk threshold of 150 mg/kg. What is the estimated dose ingested? Round off to the nearest whole number.

## 보기

1. 214 mg/kg, above the level of toxic risk
2. 171 mg/kg, above the level of toxic risk **✔ 정답**
3. 43 mg/kg, below the level of toxic risk
4. 857 mg/kg, far above the level of toxic risk

**정답: 2**

## 해설

The child drank 60 − 12 = 48 mL. At 250 mg per 5 mL (50 mg/mL), that is 2,400 mg, and 2,400 mg ÷ 14 kg = 171 mg/kg. Toxic risk begins at an acute ingestion of about 150 mg/kg, so the child needs a serum level and possible acetylcysteine even though the child looks well; early symptoms are often absent.

## 심화 해설

Dose calculation and toxic-risk interpretation

The child ingested 48 mL of syrup, calculated as the 60 mL full bottle minus the 12 mL remaining. Because the syrup contains 250 mg per 5 mL, the concentration is 50 mg/mL. Multiplying 48 mL by 50 mg/mL gives 2,400 mg of paracetamol. Dividing by the child's weight of 14 kg yields an estimated ingested dose of 171 mg/kg, which is above the hospital's toxic-risk threshold of 150 mg/kg.

The calculation itself is straightforward, but the clinical priority is recognizing that a dose above 150 mg/kg requires serum paracetamol measurement and consideration of acetylcysteine even when the child appears well. Early after acute ingestion, children frequently remain asymptomatic or show only nonspecific findings such as vomiting, so a playful appearance does not exclude hepatotoxic risk.

Why the threshold matters in pediatric paracetamol exposure

Acute paracetamol hepatotoxicity is dose-dependent. At therapeutic dosing, the liver conjugates the drug via glucuronidation and sulfation, with only a small fraction oxidized to the reactive metabolite N-acetyl-p-benzoquinone imine, which is rapidly neutralized by glutathione. After a large single ingestion, sulfation and glucuronidation become saturated, and glutathione stores are depleted. The unbound reactive metabolite then binds hepatocellular proteins, initiating centrilobular necrosis.

The 150 mg/kg threshold is used because below this level clinically significant hepatotoxicity is uncommon in otherwise healthy children, while above it the risk rises enough to warrant biochemical evaluation. Key point! The threshold is a screening trigger for obtaining a serum paracetamol level and plotting it on the Rumack-Matthew nomogram, not a diagnosis of toxicity by itself.

Why a normal-looking child still needs workup

The case report by Chiew and colleagues illustrates this principle well. A 3-year-old girl weighing 15.4 kg ingested up to 240 mg/kg of liquid paracetamol, yet her 2-hour and 4-hour serum concentrations were 105 mg/L and 97 mg/L, respectively, both below the nomogram treatment line. Acetylcysteine was withheld. However, her ALT was already elevated to 52 U/L at 4 hours and subsequently rose to 219 U/L, demonstrating that even ingestions above the toxic-risk threshold can produce early biochemical injury despite sub-threshold serum levels on the nomogram [1].

This reinforces that the estimated dose of 171 mg/kg is not merely a math exercise; it is the trigger that justifies obtaining timed serum paracetamol concentrations and baseline liver enzymes, regardless of the child's reassuring clinical appearance.

Clinical context: accidental liquid paracetamol ingestion in young children

Accidental ingestion of liquid paracetamol by preschool children is common. Babić and colleagues reviewed 466 cases of unintentional ingestion of non-opioid analgesics in children aged 0–5 years and found that paracetamol accounted for 20% of cases, second only to ibuprofen . In 94% of cases, the child ingested medication that had been left within reach while unsupervised . This matches the scenario: a full bottle of syrup left accessible to a 3-year-old.

The important distinction for nursing assessment is between a single acute overdose and repeated supratherapeutic dosing. Heubi and colleagues described 47 children who developed hepatotoxicity after receiving 60 to 420 mg/kg/day for 1 to 42 days, with markedly elevated aminotransferases . In the current scenario, the ingestion is a single acute event, so the nomogram approach applies. However, the nurse must clarify the timeline carefully: if the child had been given repeated doses before the accidental ingestion, the risk interpretation would change.

Nursing priorities and monitoring

Watch out! Vomiting occurred once, but a single episode does not reduce the estimated ingested dose. Gastric decontamination with activated charcoal is generally not indicated more than 1 hour after ingestion unless the amount is massive and the airway is protected, and it is not a substitute for antidotal therapy.

The nursing responsibilities after calculating the dose include obtaining a serum paracetamol level at 4 hours post-ingestion or as soon as possible thereafter if presentation is delayed, drawing baseline AST, ALT, INR, and creatinine, and preparing for possible acetylcysteine administration. Acetylcysteine is most effective when started within 8 hours of ingestion, so the window for intervention is narrow and the nurse's role in timely recognition and escalation is central.

Comparison of key concepts

| Concept | Single acute overdose | Repeated supratherapeutic dosing |
| --- | --- | --- |
| Typical scenario | Child finds and drinks syrup once | Caregiver gives adult-strength product or excessive doses over days |
| Risk assessment tool | Serum level on Rumack-Matthew nomogram | Clinical picture plus AST/ALT trends, not nomogram |
| Key threshold | 150 mg/kg acute ingestion | 60 to 420 mg/kg/day for 1 to 42 days |
| Early symptoms | Often absent or only vomiting | Nausea, vomiting, malaise, then hepatic injury |
| Nursing priority | Timed serum level, acetylcysteine if indicated | Stop paracetamol, monitor liver function, acetylcysteine if injury present |

The estimated dose of 171 mg/kg places this child above the 150 mg/kg toxic-risk threshold, so serum paracetamol measurement and possible acetylcysteine are indicated even though the child currently appears playful and has vomited only once.References (research sources)

- [1]Hepatotoxicity in a child following an accidental overdose of liquid paracetamol.Research articleChiew AL, Domingo G, Buckley NA, Stathakis P, Ress K, Roberts DM (2020) · DOI: 10.1080/15563650.2020.1722150

## 임상 시나리오

Pediatric Acetaminophen Overdose: Dose Calculation and TriageA playful child can still be above the toxic threshold
Calculate ingested dose as volume consumed × concentration ÷ weight. For this child, 48 mL × 50 mg/mL ÷ 14 kg = 171 mg/kg, which exceeds the toxic-risk threshold of 150 mg/kg.

Any acute ingestion above 150 mg/kg requires serum acetaminophen level measurement and consideration of acetylcysteine, regardless of clinical appearance.

CautionEarly after ingestion, children are often asymptomatic or have only vomiting. A playful appearance does not exclude hepatotoxic risk; do not delay antidote preparation while awaiting symptoms.

## 핵심 개념

- **Acetylcysteine** — Antidote for acetaminophen overdose that replenishes glutathione and prevents hepatotoxicity.
- **N-acetyl-p-benzoquinone imine** — Reactive toxic metabolite of acetaminophen that binds hepatocellular proteins when glutathione is depleted.
- **Toxic-risk threshold** — Acute acetaminophen dose above which serum level measurement and antidote are indicated, typically 150 mg/kg in children.
- **Centrilobular necrosis** — Pattern of liver cell death in the zone around the central vein, characteristic of acetaminophen hepatotoxicity.
- **Glutathione** — Hepatic antioxidant that neutralizes acetaminophen's reactive metabolite; depleted in overdose.

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