17 year old male (weight 64kg) with no past medical history presents after taking 50 X 500mg paracetamol tablets 12 hours prior to presentation. He is nauseous and has mild epigastric pain

Blood results are as follows:

Paracetamol level -122mg/l

ALT 207 U/L

Normal U and E’s

1. What is your risk assessment for this patient
2. What your management of this patient

Repeat ALT is done at the end of 20 hours of NAC – 506 U/L. NAC is continued and  ALT is repeated 17 hours later – 1240 U/L

3.What further investigations and management is required? What are the end points for management for this patient?