Paracetamol

A 25-year-old woman is brought to the emergency department by ambulance after her housemate found her with an empty blister pack, 2 hours after she reportedly ingested 30 × 500 mg paracetamol tablets (15 g, approximately 214 mg/kg) in a single act of self-harm. She admits to the ingestion, denies co-ingestants, and has no significant past medical history. She is alert and cooperative, denies nausea, vomiting or abdominal pain, and examination is unremarkable. Observations are: HR 78 bpm, BP 118/72 mmHg, RR 16/min, SpO2 99% on room air, temperature 36.7°C. What is the most appropriate immediate management?

A 32-year-old woman is brought to the emergency department by ambulance four hours after intentionally ingesting approximately 40 g of paracetamol (eighty 500 mg tablets) in a single episode, witnessed by her partner. She complains of nausea and has vomited twice but denies abdominal pain. She has no significant past medical history and takes no regular medications. On examination she is drowsy but rousable to voice, GCS 14, heart rate 112 bpm, blood pressure 102/64 mmHg, respiratory rate 26/min, temperature 36.8°C, and oxygen saturation 98% on room air. A venous blood gas shows pH 7.28, lactate 4.6 mmol/L, and bicarbonate 15 mmol/L. A serum paracetamol concentration taken at four hours post-ingestion returns at 1200 mg/L, well above the treatment line on the paracetamol nomogram. Liver function tests, coagulation studies and renal function are pending. Which of the following represents the most appropriate management?

A 35-year-old woman is brought to the emergency department by her partner with agitation and confusion that developed over the past two hours. She has a history of major depressive disorder treated with fluoxetine and was recently commenced on tranylcypromine, a monoamine oxidase inhibitor, by her psychiatrist after a medication switch without an adequate washout period. On examination she is diaphoretic and flushed, with a temperature of 39.4°C, heart rate 138 beats per minute, blood pressure 172/96 mmHg and dilated pupils. She is tremulous, with inducible clonus and hyperreflexia that are more pronounced in the lower limbs than the upper limbs, and mild rigidity of the lower limbs. Her neck is supple and there is no photophobia. Venous blood gas shows a mild metabolic acidosis with lactate 3.1 mmol/L. Which of the following is the most appropriate next step in management?