Fifteen-Year-Old With an Acetaminophen Ingestion Who Wants to Leave

Medical priorities

• Airway, breathing, circulation, vital signs and point-of-care glucose; establish IV access.
• Calculate the dose: 20 × 500 mg = 10,000 mg, or about 182 mg/kg. That exceeds the 150 mg/kg toxic threshold, so this is a potentially lethal ingestion even though she looks well. Acetaminophen toxicity is silent for the first 24 hours; the absence of symptoms is not reassurance.
• Draw a timed acetaminophen level (4 hours post-ingestion is the interpretable time), plus liver enzymes, INR, electrolytes, renal function, lipase, salicylate, ethanol, and urine pregnancy test; obtain an ECG.
• Contact the poison centre and be ready to start N-acetylcysteine if the level is on or above the treatment line, the time of ingestion is uncertain, or the level cannot be obtained promptly. Do not wait for liver enzymes to rise.

Screen for

• Co-ingestants: what is in the house, other people's medications, alcohol, recreational drugs, and whether she vomited.
• Previous attempts, self-harm history, current stressors, and whether there is a firearm or stockpiled medication at home.

Responding to the mother

• Non-judgementally reframe: taking an overdose is a signal of distress, and intent does not change the medical danger.
• Do not shame the adolescent in front of her parent; give the mother a constructive role and explain what will happen next.
• Avoid promising secrecy, and explain the limits of confidentiality up front.

Separate the legal question from the clinical one.

• Emergency treatment may proceed under implied consent when delay would risk serious harm; a potentially lethal ingestion qualifies. Do not let a consent debate delay N-acetylcysteine if it is indicated.
• Most jurisdictions allow adolescents to consent to their own mental health assessment, and many allow confidential care for certain conditions; the exact rules vary by state or province, so confirm with the charge nurse, risk management or the on-call administrator.

Practical approach with the adolescent

• Explain, briefly and without coercion, why the blood test matters and what the result will change.
• Offer control where you can: who is present, which arm, numbing spray, timing.
• Involve child life, and give her a moment alone with the nurse to talk without her mother.
• If she continues to refuse, escalate to the physician, psychiatry consultation and risk management; treatment refusal in a suicidal adolescent is a capacity question, not a simple 'no', and discharge is not an option.

If the parent refuses necessary testing or treatment, escalate to social work and, if required, child protective services or a court order; document every step, who was contacted, and the times.

Reasoning. The judgement being tested is maintaining the therapeutic relationship and safety while not allowing consent processes to become a reason to under-treat.

Medical clearance

• Acetaminophen level interpreted against time of ingestion, with N-acetylcysteine started if indicated and the course timing documented.
• Liver enzymes and INR at baseline and trending; other ingestions excluded; the patient tolerating oral intake or receiving intravenous therapy.
• Repeat levels and a clear plan for the next blood draw.

Psychiatric safety before any disposition

• One-to-one observation from arrival: search belongings, remove sharps, cords, belts, medications and glass, gown the patient, and do not allow unsupervised bathroom use.
• A documented suicide risk assessment by a qualified clinician before discharge is mandatory. Medical clearance is not psychiatric clearance.
• A legal hold per the local statute if she meets criteria; document the rationale and who authorised it.
• Safety planning with the family, including means restriction: lock away medications, remove firearms, and give crisis-line information.

If transferring 60 km for a psychiatric bed

• Transfer only when medically stable, with a sitter and appropriate transport.
• Handoff using a structured format: time and amount of ingestion, level and interpretation, N-acetylcysteine start time and remaining course, co-ingestants, psychiatric findings, legal hold status, family contact and the receiving clinician who accepted.

Never discharge her from the emergency department after 'medical clearance' alone because there is no psychiatric bed available; escalate until an appropriate disposition exists.