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Tsao S-W, Tsang CM, To K-F, Lo K-W

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Increased time to NAC is associated with increased risk of spontaneous abortion (Wilkes 2005, Riggs 1989) Chronic heavy alcohol use Acute alcohol coingestion with APAP may be hepatoprotective (Waring 2008) Chronic heavy EtOH use may place someone at higher risk if they did NOT coingest EtOH with their APAP overdose (Bunchorntavakul 2018) Recommendation: use the nomogram as for those without a history of chronic heavy EtOH use Rationale: Patients with chronic heavy EtOH use were included in the derivation of the nomogram Take home points APAP overdose is a common cause of acute liver failure in the United States and has significant morbidity/mortality APAP toxicity is often clinically silent in the first phase of overdose Evidence base is strongest for acute ingestions, in which the nomogram should be used to guide management with NAC Evidence is weaker and the clinical picture is more complex for unknown time of ingestion, extended-release APAP, IV APAP, chronic overdose, pregnancy, and in patients with chronic heavy EtOH use