Emergency Department Diagnosis and Management of Acetaminophen or Salicylate Toxicity (Pharmacology CME)

Publication Date: September 2026 (Volume 28, Number 9)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 09/01/2029.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits, subject to your state and institutional approval.

Authors

Linda Johnson, MD, PhD

Assistant Professor, Emergency Medicine and Medical Toxicology, University of Massachusetts Chan Medical School, Worcester, MA

Richard Church, MD, FACEP, FACMT

Professor, Emergency Medicine and Medical Toxicology; Program Director, Emergency Medicine Residency Program, UMass Memorial Health, University of Massachusetts Chan Medical School, Worcester, MA

Abstract

Acetaminophen and salicylate are among the most widely used nonprescription analgesics and are common causes of toxic medication overdose. Diagnostic and management approaches differ depending on whether toxicity results from a single acute ingestion or chronic supratherapeutic use. Although acetaminophen and salicylate toxicity are well studied, controversies remain regarding management. This review presents a systematic approach to the emergency department management of patients with acetaminophen or salicylate toxicity, including discussion of the tools used to assess severity, guide treatment decisions, and determine prognosis.

Case Presentations

CASE 1

An 18-year-old woman presents after intentionally ingesting an overdose of acetaminophen...

She reports taking 10 g of acetaminophen as a suicide attempt 4 hours before arrival. She denies co-ingestants.
Her vital signs are within normal limits, and she is actively vomiting.
Laboratory results sent from triage are notable for a 4-hour acetaminophen level of 165 mcg/mL, an AST level of 20 U/L, and an ALT level of 15 U/L.
The nurse asks if she can be cleared for psychiatry, but you wonder if medical treatment is needed…

CASE 2

A 40-year-old man presents with dental and abdominal pain...

He reports that he has been taking acetaminophen, acetaminophen with oxycodone, and acetaminophen with hydrocodone over the past week for ongoing dental pain. He also notes abdominal pain, nausea, and vomiting starting today.
His vital signs are within normal limits. On examination, right upper quadrant tenderness is noted.
His laboratory results are notable for an AST level of 12,785 U/L, an ALT level of 10,545 U/L, and an undetectable acetaminophen level. Liver function tests performed 1 month ago showed normal results.
You wonder if you should give this patient N-acetylcysteine…

CASE 3

A 25-year-old woman presents with tinnitus after taking an unknown quantity of “back and body pain relief” tablets...

She reports that she took the tablets 1 hour before arrival at the ED but does not recall how many she ingested.
She is awake and endorses a ringing sensation in her ears.
She shows you the medication packaging, which indicates that each tablet contains 500 mg salicylate and 32.5 mg caffeine.
Initial laboratory results show a salicylate level of 84 mg/dL and an undetectable acetaminophen level.
You consider the treatment options for this patient, including the possible need for hemodialysis…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Emergency Department Diagnosis and Management of Acetaminophen or Salicylate Toxicity (Pharmacology CME)

Abstract

Case Presentations

Accreditation:

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