Hepatotoxicity is extremely rare in patients treated with acetylcysteine within 8 hours of an acute paracetamol overdose. Presentation with coma may also occur if a combination preparation of paracetamol and opioid is taken in overdose, or after an overdose of multiple drugs. Rarely, massive overdose may initially present with coma and severe metabolic acidosis. Untreated paracetamol poisoning may cause varying degrees of liver injury over the 2 to 4 days following ingestion, including fulminant hepatic failure. Patients are often asymptomatic or have only mild gastrointestinal symptoms at initial presentation. Overdose may occur after excessive ingestion of paracetamol or paracetamol-containing medication as an acute or staggered overdose, or therapeutic excess.
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