Page 639 - ACCCN's Critical Care Nursing

616 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Case study
0750h 0815h
Maria Baxter, a 42-year-old woman, presented to the ambulance The Poisons Information Hotline was contacted for advice, with the
bay of the ED with her family in a private car for evaluation after a following information provided:
suspected overdose of insecticide. Maria’s partner and sister l symptoms may have a delayed onset
approached the triage area stating that the patient had taken l the solution contains active metabolites
‘another overdose and was vomiting’. At this stage they gave no l a serum cholinesterase level should be collected
warning to the emergency staff of the type of ingestion. The initial l an oral dose of activated charcoal should be administered
history was difficult due to the dysfunctional communication by l a dose of atropine may be given as a heart rate response test
the family members present. Questioning of Maria’s sister by the l administration of pralidoxime was suggested if there was no
triage nurse revealed that the patient had deliberately drunk response to atropine or an exacerbation of symptoms was
approximately one cup of ‘insect killer’. seen.
The triage nurse protected herself (minimally) with a pair of gloves 0825h
and a patient gown, then went to assess Maria, who was sitting in Maria’s pulse rate was noted to be 110 beats/min. A dose of atro-
the backseat of the car. On initial triage assessment, the patient pine 0.5 mg IVI was administered and her pulse rate rose to 125. A
was alert and able to talk, stating that she ‘felt unwell’ and relaying chest X-ray was also ordered.
what had happened. The triage nurse noted that the patient had
vomited recently and that there was a strong smell of a garlicky 0830h
oil-type substance coming from the car. The triage nurse immedi- Maria developed mild sweating of the face and forehead. There
ately removed herself from the area and contacted the shift coor- was no increase in salivation but a large amount of clear saliva was
dinator of the ED to inform her of the incident, the need for noted on the tongue. No muscle fasciculations were evident, and
assistance and that staff should adopt a standard approach to a Maria’s pupils fluctuated from 4 mm to 1 mm in size. On ausculta-
chemically contaminated patient. tion her chest was clear, and good power was evident in all limbs.
Maria remained in the car while staff prepared a treatment area At this time, staff discussed Maria’s progress with her concerned
that was isolated from the department (a single room with family, including the potentially serious nature of the ingestion,
negative-pressure air flow and high-volume air extraction). Staff and offered emotional support.
also applied personal protective equipment (PPE) to guard them 0845h
selves from contamination with the substance. Three suitably-
clothed nursing staff helped Maria from the car. After minimal Maria developed widespread muscle tremors but retained good
assessment, she was taken to an external shower, where she had muscle strength, including the ability to cough and maintain ade-
her clothing removed and placed in a sealed contaminated-waste quate respiratory function. Her pulse rate rose to 144 beats/min
bag. The patient was then given a shower using warm, soapy water. with a blood pressure of 140/90 mmHg. A pralidoxime loading
It was noted at this point that an oily substance on and around her dose was ordered (1 g in 100 mL isotonic saline) and commenced
mouth and hands turned white when water was applied. This was over 30 minutes, followed by a pralidoxime infusion (at 400 mg/h).
thoroughly removed and Ms Baxter was placed in the isolation 0850h
room of the ED.
An ICU review was requested and Maria was seen by the intensive
0803h care consultant. The consultant agreed with the current manage-
Maria was formally triaged with an ATS of 2, based on her exposure ment plan and accepted Maria as a suitable admission to the ICU.
to the chemical and the level of response required. Her initial At that time a bed was available and ready. The earlier chest X-ray
observations were: alert with pink, warm and dry skin; pulse 72 was reviewed and noted to be clear. The ICU consultant also noted
beats/min; blood pressure 117/71 mmHg; oxygen saturation that the ECG showed a sinus tachycardia with no rhythm distur-
100%. Cardiac monitoring and supplemental oxygen therapy (6 L/ bances. At this time, emergency staff caring for Maria began com-
min via Hudson mask) were commenced. An IV cannula was plaining of nausea and headaches. A rotation of the staff caring for
inserted by an ED nurse and venous blood samples were collected Maria was commenced.
for haematology and biochemistry.
0900h
0810h Maria had an increase in sweating, further diarrhoea, had devel-
Initial medical assessment noted the following additional history: oped a cough, and increased salivation which required suctioning.
l Maria vomited twice, once in the car and once in the ED; this But Maria was still able to talk, and her GCS remained at 15. Other
was followed by an episode of diarrhoea. observations were: heart rate 130, respiratory rate 24, blood pres-
l Maria had taken an intentional ingestion of chlorpyrofos, esti- sure 140/95, and oxygen saturation 99%.
mated to be approximately half a cup at 0630–0645h. Maria
stated that she wanted to kill herself. 0910h
l The family appeared asymptomatic. With an ICU bed available, a transfer to the ICU was undertaken.
l On the container supplied by the family, the information label Maria was transferred with full monitoring and resuscitation equip-
read ‘Super Buffalo Fly Insecticide, 20% chlorpyrofos, 65% ment and with the ICU consultant, emergency physician and an
liquid hydrocarbon’. emergency nurse escort.