Page 624 - ACCCN's Critical Care Nursing

Emergency Presentations 601

Assessment consciousness, seizure activity, or a loss of protective gag,
Both psychological and physical symptoms are produced. corneal and swallow reflexes. Nystagmus is a classic sign,
A patient may demonstrate repetitive, non-purposeful along with hypertension and an elevated body tempera-
movements, grind their teeth and appear suspicious ture. A significant rise in arterial pressure presents a risk
or paranoid of others. Physiological stimulation causes for intracerebral haemorrhage. One of the distinguishing
an increase in metabolism, with flushing, diaphoresis, features of amphetamines is their ability to produce coma
112,119
hyperpyrexia, mydriasis (excessive pupillary dilation) and without affecting respirations. The patient may be at
vomiting evident. Dizziness, loss of coordination, chest risk of dehydration and renal failure if muscle breakdown
pain, palpitations or abdominal cramps may also be has occurred. A high urine output should be maintained
present. During the acute phase of poisoning, severe and serum urea and creatinine levels monitored to detect
112,118,119
intoxication and loss of rational mental functioning may a decrease in renal function.
lead individuals to behave irrationally and even attempt Lower-dose intoxications do not produce unconscious-
suicide. Anxiousness and a general state of tension may ness but typically cause behavioural patterns that reflect
also lead the affected person to attempt to harm depersonalisation and distorted perceptions of events or
others. 112,118,119 Death is possible from cardiovascular col- other people. The patient’s physical and mental responses
lapse or as a sequela to convulsions and acute drug may be dulled and slow, or their behaviour abusive and
toxicity. 112,118,119 delusional. Intoxication is marked by paranoid thoughts,
with the patient responding to therapeutic or friendly
Management gestures with behaviours ranging from apprehension to
If a patient has ingested the drug, emesis or lavage is of aggressive hostility. To avoid stimulating the patient and
little value, and an individual risk–benefit assessment is intensifying their behaviour, use a quiet environment for
required. Gastric emptying may precipitate more severe initial assessment and treatment, although this is often
agitation with a concomitant rise in blood pressure, pulse difficult in the ED. 112,118,119
rate and metabolism. 112,118,119 Activated charcoal and
cathartics may be administered to promote elimination. Management
Note that there are no specific antidotes for CNS stimu- Gastric emptying is normally ineffective due to delays in
lants. Ongoing emergency management includes:
seeking treatment. If a patient presents early, activated
l support of vital functions 112,118,119 charcoal and cathartics are useful in preventing further
l reduction of external stimulation by locating the absorption. Noises, sights and sounds provoke paranoid
patient in a quiet, non-threatening environment ideation and may present a risk to staff and other
where a supportive person can attempt to calm and patients. ‘Talking down’ is usually not successful and
‘talk the person down’ while observing for untoward probably only serves to exacerbate the situation. If the
reactions patient is demonstrating hostile or self-abusive behav-
l sedation when necessary, although it is not desirable iour, restraints may be needed to protect him/her and
to give more medications in a precarious situation; any others present. The use of physical restraints is not
sedation may control seizures or keep the patient from without danger, and they should never be used as a sub-
self-harm. 112,118,119 stitute for a more desirable environment. If the threat of
danger or psychosis is significant, sedatives (diazepam,
AMPHETAMINES AND DESIGNER DRUGS haloperidol) may be necessary to control the patient’s
behaviour. Intravenous diazepam also controls frequent
Amphetamines and designer drugs have been drugs of 112,118,119
abuse for a number of years. Originally, many were seizure activity.
designed and introduced as anaesthetic agents, deconges-
tants or for other legitimate purposes. Amphetamines are SALICYLATE POISONING
chemically related to the anaesthetic ketamine, with a Aspirin is the most common form of salicylate in the
similar CNS response. 112,118,119 Most drugs in this group home and is found in many over-the-counter medica-
were discontinued or controlled because of the delirium tions, such as combination analgesics 122 and topical
and agitation experienced by patients who received them; ointments. Aspirin may be ingested orally, absorbed
paradoxically, these effects led to their popularity as through the rectal mucosa, or applied to the skin in
recreational drugs. 112,118,119 Amphetamines are synthetic topical preparations. Under normal circumstances, the
sympathomimetic drugs, available in oral, intranasal or kidneys serve as the principal organ of excretion. Aspirin
intravenous forms; crystalline rock forms such as ‘ice’ are was previously the most common poisoning in chil-
smoked. Death may occur from overdose, self-mutilation dren, 106,109,122 so legislation was implemented to limit
or dangerous activities such as diving into shallow waters the number of tablets per pack and to introduce packag-
or walking on traffic-laden roads. ing with childproof caps. In Australia, salicylate poison-
ing is now uncommon, accounting for only 0.3% of
Assessment calls to poison information centres. 106,122 The three
Depending on the dose, route and time since exposure, common types of aspirin overdose are: accidental inges-
a person exhibits characteristic behavioural and tion (more common in young children); intentional
physical changes. With high-dose intoxication, the patient ingestion (more common in adults); and chronic toxicity
has pronounced CNS involvement: altered levels of (occurs in any age group). 115,122