A 22-year-old presents 36 hours after a staggered paracetamol overdose. INR 6.8, creatinine 220, pH 7.28, lactate 5, drowsy (GCS 12). What is your management?

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This patient has **paracetamol-induced acute liver failure** — INR 6.8, AKI, lactic acidosis and grade II encephalopathy at 36 hours. She already meets criteria that should trigger **immediate transplant centre contact**. **Resuscitate (ABCDE).** Airway — GCS 12 and falling; threshold for **intubation** is low if encephalopathy progresses to grade III. IV access, fluid resuscitation, vasopressors if needed targeting MAP ≥65. **Antidote.** **N-acetylcysteine** at the standard 21-hour regimen, continued beyond standard duration in established hepatotoxicity until INR is improving (<1.3) per TOXBASE / RCEM guidance. NAC has benefit even in late presentation. **Specific organ support.** - **Neurological:** head up 30°, avoid hypotonic fluids, target serum **Na 145–150 mmol/L** to reduce cerebral oedema; **mannitol 0.5 g/kg or 3% saline** for raised ICP. Avoid sedatives that mask exam unless intubated. - **Renal:** early **CVVHDF** for AKI, acidosis, lactate clearance. - **Coagulation:** do **not** routinely correct INR — it is the prognostic marker the transplant team needs; replace only for active bleeding or pre-procedure. - **Metabolic:** 10% dextrose infusion, hourly glucose monitoring (hepatic hypoglycaemia). - **Infection:** broad-spectrum antibiotics ± antifungal — sepsis is a major cause of death and a contraindication to transplant. **King's College Criteria for paracetamol ALF.** Listing criteria are: - Arterial **pH <7.30** after resuscitation (pH 7.28 — already met), OR - **INR >6.5 + creatinine >300 µmol/L + grade III–IV encephalopathy** all three. She meets the pH criterion already. **I would phone the regional liver transplant unit immediately** for super-urgent listing assessment; do not delay for additional criteria. **Communication and ethics.** Honest conversation with family about ALF mortality, the transplant assessment process, and possible psychiatric assessment given the overdose (post-stabilisation, MHA considerations only if capacity is impaired). Document mental capacity, safeguarding, and contemporaneous events. Datix if there were system delays.

Paracetamol-induced acute liver failure with worsening encephalopathy

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