A 20-Year-Old College Student Is Brought to the Emergency Department

A 20-year-old college student is brought to the emergency department by his girlfriend after he ingested large amounts of acetaminophen in a suicide attempt.  Two days ago, the girlfriend told the patient that she wanted to break up with him.  He became distraught and took approximately 30 pills of 500-mg acetaminophen to end his life.  This morning, the girlfriend discovered what he had done and brought him in to seek care.  The patient reports nausea and mild abdominal pain.  He has no history of previous suicide attempts or psychiatric illness.  Temperature is 36.7 C (98 F) , blood pressure is 114/68 mm Hg, and pulse is 94/min.  Abdominal examination reveals mild tender hepatomegaly.  Serum acetaminophen level is high, and the patient is hospitalized for N-acetylcysteine therapy.  During the hospital stay, he becomes markedly confused and incoherent.  Repeat examination shows scleral icterus and asterixis.  Current laboratory results and those obtained at the time of admission are as follows: Which of the following is the best next step in management of this patient?

A) Close monitoring only
B) Initiate vitamin K supplementation
C) Perform liver biopsy
D) Refer to liver transplant center
E) Start glucocorticoid

Correct Answer:

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