Journal Club – December 2020

Safety and Efficacy of the SNAP 12-hour Acetylcysteine Regimen for the Treatment of Paracetamol Overdose – [LINK HERE]

Wed 16th Dec 12-13:00

TEAMS meeting

  • Everyone is welcome – Nursing and medical, no experience necessary
  • Read the article  – check your emails
    • (we have emailed out to you – if not, email darren or huw and we will send a copy)
  • Your opinion – Whats good and bad about the study, would this change your practice?
  • Come along – We will discuss; how to read a paper, what everyone thinks about the paper
  • if you can’t make it – feel free to post your thoughts below so we can bring them up



  • Highly relevant to practice in the ED
  • Used a UK ED population
  • Large sample size
  • Usedall patients attending with paracetamol overdose requiring treatment
  • Good Follow-Up


  • Using 2 separate cohorts that span 2 yrs, may be convenient but may hide significant differences in both population and hospital practice
  • Anaphylactoid definition “patient prescribed antihistamine” , again convenient but prob not accurate
    • The amount of anaphylactoid reactions reported seems excessive compared to our experience (but is this because they occur more frequently outside the ED)
  • One of the aims was to examine effectiveness invarious overdose types (e.g. delayed presentation, staggerd overdose), but didn’t have the numbers for subgroup analysis
  • More staggered overdoes in the 12hr SNAP group – was this a function of teaching in preparation to changing protocol or was it truly different?


  • We agreed that the 12hr SNAP protocol seems to be an effective alternative to the current 21hr regime in preventing liver damage.

Further question generated

  • All patients meant to have bloods done at 24hrs? – good for internal validity but if put into practice negates the major benefit of the 12hr regime
  • Data on Children? – we would like to know it’s effective in a paediatric population (as do we want 2 regimes and the chance of error)
  • Is 21hr regime more effective? – it was postulated in the paper late presentations have a poorer outcome. There were significantly more late presentations in the 21hr group, but no difference in overall effectiveness (so is 21hr better?)
  • Extended 12hr regime? – we couldn’t see how many patients in the 12hr SNAP group had their treatment extended upto 21hr  (only beyond 21hr).
  • Excess repeat overdose? – in the 12hr SNAP group there was a significant 2.1% increase in repeat overdoses. Did reducing the side-effect profile and length of antidote encourage repeat overdose? OR were we seeing a variance in population behavior.


  1. Gareth Bessant says:

    Agree that if needing >20hours bloods then no improvement in length of stay, if only improvement is use of antihistamines, then cannot see clinically important advantage over familiar regieme.

    • embeds says:

      unsurprisingly a “significant” number of patients were discharged prior to the 24hr bloods in the SNAP Group (TOXBASE suggest patients can be discharged is bloods ok at the end of the 12hr regime)

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