A 45-year-old man presents with 3 days of body aches and headaches for which he has been taking large amounts of over-the-counter acetaminophen (Tylenol). He now has new-onset jaundice, confusion (hepatic encephalopathy Grade II), an INR of 3.5, ALT 4500 U/L, and AST 3800 U/L. A serum acetaminophen level drawn approximately 48 hours after his last reported dose is undetectable. Which of the following is the MOST appropriate initial pharmacologic intervention?

A 34-year-old female is admitted to the critical care unit, currently intubated and on assist-control ventilation due to progressive encephalopathy. A central venous catheter is in place, and she is receiving intravenous fluids. Her husband reports she has been feeling unwell for several days and admits to taking a large amount of over-the-counter pain relievers for a severe headache, though he is unsure of the exact product or quantity. On admission, her vital signs are stable, but laboratory results show: AST 4,500 IU/L, ALT 5,200 IU/L, total bilirubin 4.8 mg/dL, INR 3.5, and a serum acetaminophen level of 15 mcg/mL (drawn 24 hours after last reported ingestion). She has no known history of liver disease, alcohol abuse, or viral hepatitis. Considering the patient’s clinical presentation and laboratory findings, which of the following is the MOST appropriate first-line pharmacologic agent for her acute liver failure?

A 34-year-old female is admitted to the intensive care unit with altered mental status and laboratory evidence of acute liver injury following an acetaminophen overdose. She was found unresponsive at home approximately 24 hours after ingesting a large quantity of acetaminophen. Initial laboratories show: AST 4,500 U/L, ALT 5,200 U/L, total bilirubin 2.1 mg/dL, INR 3.8, and creatinine 1.0 mg/dL. An acetaminophen level drawn on admission is undetectable. Which of the following initial management strategies is MOST appropriate?

A 34-year-old man presents about 10 hours after a suspected intentional acetaminophen overdose. Laboratory evaluation shows an acetaminophen level of 250 mcg/mL (toxic >150 mcg/mL at 4 hours), AST 2,500 IU/L, ALT 3,100 IU/L, total bilirubin 2.8 mg/dL, INR 2.5, creatinine 1.0 mg/dL, and Grade 1 hepatic encephalopathy. Which of the following is the most critical initial intervention?

A 32-year-old, 60-kg female is admitted to the ICU with acute liver failure secondary to a suspected acetaminophen overdose. She presents 8 hours after ingestion with an acetaminophen concentration of 200 µg/mL (above the Rumack-Matthew treatment line), AST 4500 U/L, ALT 5200 U/L, INR 3.5, and grade II hepatic encephalopathy. She is intubated on assist-control ventilation and has a central venous catheter for vasopressor support. Which of the following N-acetylcysteine (NAC) regimens is most appropriate to initiate?

A 45-year-old man is admitted to the critical care unit with acute liver failure (ALF) suspected to be due to an acetaminophen (APAP) overdose. He is intubated, on mechanical ventilation, and requires a low-dose norepinephrine infusion via a central venous catheter. Initial labs show AST 4,500 IU/L, ALT 3,800 IU/L, INR 3.5, and a detectable APAP level. Which of the following is the most appropriate initial N-acetylcysteine (NAC) administration strategy for this patient?

A 28-year-old female is admitted to the intensive care unit with acute liver failure following a suspected acetaminophen overdose. She was found unresponsive at home with empty acetaminophen bottles nearby and is intubated for airway protection due to hepatic encephalopathy. Initial laboratory results reveal AST 4500 U/L, ALT 3800 U/L, INR 3.5, total bilirubin 2.1 mg/dL, and a serum acetaminophen level of 150 mcg/mL drawn approximately 10 hours after ingestion. Which of the following is the most appropriate initial pharmacologic intervention to address the underlying cause of her liver injury?

A 35-year-old woman (weight 70 kg) is admitted with suspected acetaminophen-induced acute liver failure, evidenced by markedly elevated transaminases and coagulopathy. She is intubated and cannot tolerate oral medications. Which of the following intravenous N-acetylcysteine regimens is most appropriate to initiate?

A 32-year-old woman presents with acute liver failure after a massive acetaminophen overdose reportedly ingested 3 hours prior. She is intubated with a cuffed endotracheal tube, sedated with propofol, and mechanically ventilated. Initial labs reveal an acetaminophen level of 250 mcg/mL, INR 2.5, and markedly elevated aminotransferases. Intravenous N-acetylcysteine has been started. Which of the following interventions carries the highest risk of causing severe aspiration pneumonia in this patient?

A 45-year-old man is admitted to the intensive care unit with acute liver failure secondary to acetaminophen overdose. He is intubated and receiving assist-control ventilation, and a nasogastric tube is in place with confirmed functional gastric access. Intravenous N-acetylcysteine (NAC) was initiated on arrival but was interrupted when the patient’s peripheral IV infiltrated, and central line placement is delayed due to severe coagulopathy (INR 4.5, platelets 35,000/mcL). Given the need to continue antidote therapy via the oral route, which of the following oral NAC regimens is most appropriate to initiate?