Suspected paracetamol overdose — 8-year-old male

Patient Information

Dispatch: You are called to the first aid tent at the Fremantle Family Festival. A parent has brought in their 8-year-old son after finding him with an open bottle of children's paracetamol — she is unsure how many tablets he has taken.
Patient: Liam Hargreaves — 8yr (26kg)
Incident History: Mum found Liam sitting on the ground near the family's picnic bag approximately 20 minutes ago with an open 24-tablet bottle of Children's Panadol 120mg chewable tablets. She estimates the bottle was around half full before today. Liam says he had a headache and helped himself. He is now complaining of nausea and abdominal pain.
Emergency Contact: Sarah Hargreaves (Mother) — 0412 774 903

Initial Rapid Assessment

Response: Alert
Airway: Patent. No airway obstruction. No stridor. Speaking in full sentences.
Breathing: Adequate. No increased work of breathing. No accessory muscle use. Chest rise equal bilaterally.
Circulation: Radial pulse present, regular, adequate rate. Skin warm, mild pallor. No external bleeding.
Disability: GCS 15 (E4V5M6). Alert and oriented to time, place and person. Mildly distressed and tearful.
Exposure: No rash, no visible injuries. Abdomen soft on inspection. Empty and partially empty paracetamol blister packs visible in family bag.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	99% (RA)	Nil	22	104	98/64	<2s	15	4 4 ++	37.1	4.8 mmol/L	4
10 mins	99% (RA)	Nil	20	98	100/66	<2s	15	4 4 ++	37.1	4.8 mmol/L	4

History Taking

Treatment Response

Diagnosis

This patient is suffering from a suspected paracetamol overdose (unintentional) with an unknown quantity of Children's Panadol 120mg chewable tablets ingested approximately 20–30 minutes prior to EHS arrival.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not attempt to calculate dose or count remaining tablets: Mum reports the bottle had approximately 12 tablets left before today, meaning up to 12 tablets may have been consumed — 12 × 120mg = 1440mg total. At 26kg, this is approximately 55mg/kg, which exceeds the maximum recommended daily dose of 60mg/kg and approaches potentially toxic thresholds. Prompt the trainee: 'Can you work out how much he may have taken?')
! (If the trainee does not ask about other paracetamol-containing products e.g. cold and flu tablets, combination analgesics: Mum mentions she had some Codral in the bag as well — the trainee must ask specifically about all medications to rule out co-ingestion.)
! (If the trainee attempts to administer paracetamol for the patient's headache: remind them that any paracetamol-containing product within the last four hours is a contraindication to further paracetamol administration per the Paracetamol CPG.)
! (If the trainee does not contact the Poisons Information Centre or escalate to higher care within 5 minutes of assessment: Liam begins to vomit and his nausea worsens. Facilitator advises: 'Mum is asking what you are going to do — the hospital is 15 minutes away.')
! (If the trainee does not consider ondansetron for active vomiting: patient vomits a second time. Prompt: 'He's vomiting again — is there anything you can do for the nausea?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE prior to patient contact.
2 Perform a structured Primary Survey — confirm patent airway, adequate breathing, adequate circulation, GCS 15.
3 Obtain a full set of baseline vital signs including BGL, temperature, SpO2, HR, RR, BP, pain score.
4 Perform a thorough IMISTAMBO-structured history, specifically asking: agent (paracetamol 120mg chewable), dose (count remaining tablets — estimate up to 12 tablets = 1440mg = approximately 55mg/kg at 26kg), time since ingestion (20–30 minutes), and clinical features (nausea, abdominal pain, no CNS depression).
5 Ask specifically about ALL medications in the bag to rule out co-ingestion (e.g. Codral or combination products).
6 Confirm no paracetamol or paracetamol-containing products given in the past 4 hours — DO NOT administer further paracetamol.
7 Do NOT induce vomiting.
8 Collect all medication packaging and place in patient medications bag for handover to ambulance/ED staff.
9 Consider administering Ondansetron 4mg sublingual tablet for active vomiting or moderate to severe nausea — Liam is >4 years and >15kg. Dose: Ondansetron 4mg sublingual tablet (single dose, not repeated). Confirm no hypersensitivity to ondansetron prior to administration.
10 Do NOT administer analgesia (paracetamol is contraindicated; methoxyflurane is not indicated for abdominal pain of toxic aetiology in this context and patient is alert and stable).
11 Administer oxygen only if SpO2 drops below 94% — not indicated at this time. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
12 Consider contacting the Australian Poisons Information Centre (PIC) on 13 11 26 if non-time critical — in this case, arrange urgent transport and notify receiving ED.
13 Perform Secondary Survey — assess abdomen (soft, mildly tender, no guarding or rigidity), check for any additional ingestion evidence.
14 Reassess vital signs at 10 minutes post initial assessment.
15 Arrange urgent ambulance support via CSP — IMISTAMBO handover to receiving ED — paediatric overdose with potentially toxic dose requires urgent medical review and possible N-acetylcysteine administration (out of EHS scope).
16 Maintain continuous reassurance of Liam and his mother throughout.
17 Ensure receiving hospital is informed of: agent, estimated dose (1440mg — 55mg/kg), time of ingestion, current clinical status, and any treatments administered.
18 Scenario ends on arrival of ambulance and IMISTAMBO handover.
19 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Poisons & Overdoses · Paracetamol (Acetaminophen) · Ondansetron · Primary Survey · Secondary & CNS Survey · Pain Assessment

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