Executive action is needed to change national guidelines

Editorial p 1609

EDITOR—The lesson of the week by Bridger et al on deaths from low dose paracetamol poisoning was most welcome but probably titled incorrectly.1 None of the patients in the cases described took low doses of paracetamol. What did happen was that the current national guidelines for treating patients after poisoning with paracetamol failed to protect these patients.

We suspect that many doctors will have read these cases and dismissed them as poor management, assuming, for example, that the doctors concerned failed to establish the correct timing of the drug ingestion. We fear that complacency will persist with the belief that deaths will not happen if the current guidelines are adhered to properly.

One of the cases was managed in our hospital. The timing and circumstances of the poisoning seemed to be and still do seem to be clear cut. We know the time at which the paracetamol was purchased from a local shop and the time immediately after at which help was sought. These times concur with the history that was given. The concentrations of paracetamol at four hours were 22% below the national standard treatment line. We believe that the nomogram should allow for a safety margin of 22%.

We agree that there are many possible explanations for our patient's death. Our patient may have been particularly susceptible to paracetamol but equally may have taken a sequential overdose. The key point is that a treatment strategy must allow a margin of safety that allows for some degree of inaccuracy in the history or an individual patient's susceptibility to paracetamol.

We are from the hospital in the south west referred to in the article that has changed its treatment protocol to a lower treatment line. Since making this change in 1994 we have treated around an …