Initial Management of Acute Paracetamol Ingestion

In a child presenting within a few hours of an acute, significant paracetamol (acetaminophen) overdose, the immediate priority is gut decontamination to limit further absorption of the drug, before any decision on antidote therapy is made based on serum levels.

Analysis of the Options

• Induced vomiting: Not recommended in current toxicology practice. It is unreliable, can cause aspiration (especially in a young child with an unprotected airway), delays more effective decontamination, and is contraindicated after the first hour post-ingestion.
• Alkaline diuresis: This technique enhances renal elimination of drugs that are weak acids and remain un-ionized/ionized depending on urine pH (e.g., salicylates, phenobarbitone). Paracetamol is metabolized hepatically, not eliminated by this renal mechanism, so alkaline diuresis has no role in paracetamol poisoning.
• Oral N-acetylcysteine (NAC): NAC is indeed the specific antidote for paracetamol toxicity, but its administration is guided by the plasma paracetamol level plotted on the Rumack-Matthew nomogram (checked around 4 hours post-ingestion) or by a clear history of a toxic dose after risk assessment. At 2 hours, decontamination takes precedence, and starting NAC before assessing the need is not the described "initial" step in this context; oral NAC is also poorly tolerated (nausea/vomiting) and intravenous NAC is generally preferred when indicated.
• Gastric lavage: Within the first few hours (classically up to 4 hours, and definitely within the 2-hour window described here) of a witnessed, significant paracetamol ingestion, gastric lavage (or activated charcoal, where available) is the appropriate first step to reduce the amount of drug absorbed. Since the child presents at 2 hours — well within the window where decontamination is still effective — this is the correct initial management.

Conclusion

Because the child presents only 2 hours after ingesting a significant dose of paracetamol, decontamination to reduce further drug absorption is the priority. Among the options given, gastric lavage is the correct initial management; induced vomiting is unsafe and unreliable, alkaline diuresis is irrelevant to paracetamol pharmacokinetics, and NAC administration should follow risk assessment (nomogram/history) rather than being reflexively started as the very first action.