ACETAMINOPHEN POISONING: A COMPREHENSIVE REVIEW
1) Most acetaminophen is changed to harmless metabolites by
a) conjugation.
b) metabolism by cytochrome P-450 enzymes.
c) elimination in the urine.
d) elimination in the stool.
2) Acetaminophen is converted to a toxic metabolite by
a) conjugation.
b) metabolism by cytochrome P-450 enzymes.
c) elimination in the urine.
d) elimination in the stool.
3) The toxic metabolite formed by acetaminophen metabolism is:
a) cysteine.
b) glutathione.
c) glucoronide.
d) NAPQI.
4) The toxic metabolite of acetaminophen is made harmless by
a) conjugation with sulfate.
b) elimination in the urine.
c) binding to glutathione.
d) conjugation with glucuronide.
5) The toxic doe of acetaminophen is
a) ≥ 7.5 grams or ≥ 150 mg/kg.
b) ≤ 7.5 grams.
c) ≤ 150 mg/kg.
d) 10 grams.
6) Which group is less likely to suffer liver damage from acetaminophen overdose?
a) People >age 65.
b) People who use alcohol in moderation.
c) Children under the age of 5.
d) People between the ages of 10-30.
7) Acetaminophen in overdose causes liver damage by
a) shifting metabolism to conjugation.
b) producing excess amounts of NAPQI.
c) increasing the dependence on conjugation with sulfate.
d) decreasing the amount of NAPQI that is formed.
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8) The basis of acetaminophen poisoning is
a) rate/amount of NAPQI formation greater than glutathione availability.
b) rate/formation of conjugation is greater than glutathione availability.
c) decrease in glutathione effectiveness.
d) increased sensitivity of the liver to the drug.
9) One organ other than the liver that is affected by an overdose of acetaminophen is
a) the lungs.
b) the small bowel.
c) the kidneys.
d) The thyroid.
10) Which of these are signs and symptoms of Phase I of an acetaminophen overdose?
a) Nausea, vomiting, normal laboratory values
b) Nausea, vomiting, abnormal laboratory values
c) Hypotension, rhabdomyloysis, normal laboratory value
d) Cough, dyspnea, abnormal laboratory values
11) Which of these are signs and symptoms of Phase II of an acetaminophen
overdose?
a) Nausea, vomiting, normal AST, ALT, and INR.
b) Nausea, vomiting, abnormal AST, ALT, and INR.
c) Nausea, vomiting, elevated white blood cell count.
d) Normal exam, elevated AST, ALT, and INR.
12) Phase III of acetaminophen poisoning is characterized by
a) recovery.
b) liver failure
c) recovery or progression to liver failure.
d) liver failure and renal failure.
13) Phase IV of acetaminophen poisoning is characterized by
a) coagulopathies.
b) renal damage.
c) metabolic acidosis and coma.
d) return of liver function.
14) The primary toxic effect of acetaminophen overdose is
a) renal damage.
b) hemolysis.
c) metabolic acidosis.
d) liver damage.
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15) A massive overdose of acetaminophen can cause a rapid onset of
a) metabolic acidosis and coma.
b) rhabdomyolyisis and ARDS.
c) renal failure and coagulopathies.
d) coma and myocardial infarction.
16) The onset of renal damage after acetaminophen overdose is
a) usually after liver damage occurs
b) before liver occurs.
c) happens at the same time that liver damage occurs.
d) unpredictable.
17) Organ damage other than hepatic or renal is common after acetaminophen
overdose.
a) True.
b) False.
18) Which of the following is most likely to the risk for acetaminophen poisoning?
a) Age > 65, or age < 5.
b) Alcohol use, hepatitis C.
c) Cigarette smoking, obesity.
d) Elevated serum cholesterol, use of anti-coagulants.
19) Which of the following are used to assess an acetaminophen overdose?
a) Physical exam, acetaminophen level, amount ingested, laboratory values.
b) Physical exam, amount ingested, vital signs.
c) Laboratory values, physical exam.
d) Medical history, current medications, acetaminophen level, laboratory values.
20) An acetaminophen ingestion occurring over ___ hours is a chronic exposure.
a) 8
b) 12
c) 4
d) 1
21) The signs and symptoms of acetaminophen poisoning may
a) occur immediately after an ingestion.
b) be more pronounced in people >age 65.
c) are more pronounced in people with certain risk factors.
d) be absent or diminished in the first 24 hours.
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22) The liver tests used to evaluate cases of acetaminophen poisoning are
a) AST, ALT, and INR.
b) AST, PT, and creatinine.
c) ALT, INR, and BUN.
d) AST, amylase, and creatinine.
23) The acetaminophen level should obtained ___ hours after an ingestion.
a) 2
b) 4
c) 8
d) 10
24) True or False: Patients should have serial acetaminophen levels drawn.
a) True.
b) False.
25) In order to interpret an acetaminophen level as toxic or non-toxic
a) the exact dose ingested must be known.
b) the level must be drawn at the same time as the AST and ALT.
c) the level must be drawn 4 hours or later after the ingestion.
d) the level must be confirmed with another level 2 hours later.
26) The decontamination techniques for acetaminophen overdose is
a) ipecac.
b) lavage.
c) activated charcoal.
d) whole bowel irrigation.
27) The antidotal therapy for acetaminophen poisoning is
a) hemodialysis.
b) methylene blue.
c) glucagon.
d) N-acetylcysteine (NAC).
28) NAC is most effective if it is given
a) from 0 to 24 hours after an ingestion of acetaminophen.
b) from 0 to eight hours after an ingestion of acetaminophen.
c) from two to 12 hours after an ingestion of acetaminophen.
d) from four to eight hours after an ingestion of acetaminophen.
29) The primary mechanism by which NAC works to prevent liver damage is
a) increasing hepatic oxygen delivery.
b) acting as a free radical scavenger.
c) converting NAPQI back to acetaminophen.
d) increasing synthesis of glutathione.
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30) Which of the following is the oral dosing regimen for the antidote?
a) 100 mg/kg, the 17 doses of 50 mg/kg.
b) 140 mg/kg, then 17 doses of 70 mg/kg.
c) 140 mg kg, then 10 doses of 100 mg/kg.
d) 70 mg/kg, then 17 doses of 140 mg/kg.
31) Which of the following is the IV dosing regimen for the antidote?
a) 150 mg/kg in 60 minutes; 50 mg/kg in 4 hours; 100 mg/kg in 16 hours.
b) 100 mg/kg in 60 minutes; 150 mg/kg in 4 hours; 50 mg/kg in 16 hours.
c) 140 mg/kg in 60 minutes; 70 mg/kg in 4 hours; 35 mg/kg in 16 hours.
d) 50 mg/kg in 60 minutes; 100 mg/kg in 4 hours; 150 mg/kg in 16 hours.
32) When PO NAC and IV NAC have been compared
a) PO NAC is more effective.
b) IV NAC is more effective.
c) IV NAC is preferable in the case of ingestions >15 grams.
d) they are equally effective.
33) Which of the following are common adverse reactions to oral NAC?
a) Hypotension, tachycardia.
b) Nausea, vomiting.
c) Flushing, pruritus.
d) Headache, blurred vision.
34) Which of the following are common adverse reactions to IV NAC?
a) Wheezing, rash.
b) Headache, blurred vision.
c) Hypertension, tachycardia.
d) Diarrhea, orthostatic hypotension.
35) Which of these criteria are used to determine the need for liver transplantation?
a) BUN, serum pH, creatinine.
b) Serum pH, urine output, BUN.
c) Serum pH, PT, creatinine.
d) Hemoglobin, creatinine, AST.
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