College of Nursing

West Avenue, Molo, Iloilo City

ILOILO DOCTORS’ COLLEGE

NCM 118 (RLE)

Care of Clients with Life-Threatening Conditions, Acutely Ill/ Multi-Organ
Problems, High Acuity and Emergency Situations

Case Scenario No. 11

Acetaminophen Poisoning

Fiona 20 months old, weighs 14kgs, residing in Timawa, Iloilo City was left alone by her mom
Mrs. Lila in her crib as she was busy doing her household chores. She is a typical 2-year-old, who climb
stairs, chairs, and loved to be chased by cousins when awake. She can speak a few words like Mama,
Papa, drink, eat, cat, dog to mention. She is bottle feed with Bonna Kid and eats anything given to her but
manifest temper tantrums when her demands are not attended. By 11 am when Mrs. Lila checked on her
she found out that Fiona climb out of her crib and took around 6 tablets of Acetaminophen (Tylenol) out
of curiosity. Fiona climbed the table nearby and reached the bottle as she thought it is candy. Mrs. Lila
found her on generalized tonic clonic convulsion for 1 minute. She appeared, confused, vomits and
diaphoretic lying next to the bottle a few hours later. The ICER brought them to the ER of the nearest
hospital. On examination Fiona’s T=38.5 degree Celsius, PR= 60 bpm, is irregular, RR= 20 cpm and B/P
= 90/60 mmHg.O2 saturation=95%. D5 IMB 500 ml x 25 ml/ H was started. NGT insertion done and
Activated Charcoal was administered through gastric lavage until return flow is clear. Paracetamol 100
mg IVTT was given as stat dose. The child was sleepy and weak. The pupils were 1 mm in diameter and
not reactive to light. The cardiovascular, respiratory and abdominal examinations were unremarkable. The
neck was soft and Babinski response was negative bilaterally. The bedside blood sugar level was 1.8
mmol/L. Intravenous dextrose was given in the form of D10 but her clinical response was poor and she
remained sleepy after 30 ml of D10. The X-ray chest was normal. She starts to cry and regain
consciousness after 4 hours. She vomited approximately 30 ml of whitish secretions with some particles
of Acetaminophen. Fiona was placed on NPO temporarily. Mother looked anxious and cried during
history taking, feeling guilty of what happened.
After admission, her condition deteriorated with respiratory failure that required intubation and
mechanical ventilation. She was then transferred to the intensive care unit for further management. Blood
tests including complete blood picture, renal function, liver function, prothrombin time, activated partial
thromboplastin time, blood culture, and blood gas analysis, were performed. Initial liver indices were
normal. Total bilirubin level was 20.4 (normal 3–17) μmol/L, glucose level was 5.7 (normal 4–8) mmol/L
and albumin level was 33 (normal 32–45) g/L. Complete blood count, electrolytes and renal function tests
were normal. Metabolic workup including organic acid, carnitine, lactate, pyruvate, and amino acid
profile were also performed. The results revealed aspartate transaminase >3,000 U/L, alanine
transaminase >2,254 U/L, international normalised ratio >3.0. Urgent viral study excluded the possibility
of hepatitis B, hepatitis C, human immunodeficiency virus (HIV) antibody and acute cytomegalovirus
infection. ABG pH=7.30, HCO3= 18 mEq/L thus given 10 mEq NaHCO3 in 100ml of D5W x 1hr slowly
administered thru IVTT. Computerised tomography of the brain was normal but lumbar puncture was
withheld due to the deranged coagulation profile. Urgent electroencephalogram revealed generalised
slowing. Toxicology screen showed that the paracetamol level was 556 µmol/L at 8-hour. N-
acetylcysteine (Mucumyst) was initiated, starting with 1,800 mg in 200 ml dextrose over 1 hour, then 630
mg in 150 ml dextrose over 4 hours, then 1,200 mg in 250 ml dextrose over 16 hours and finally 1,200
mg in 250 ml dextrose over 24 hours. Besides, urine toxicology tests revealed the presence of
benzodiazepine, mefenamic acid, chlorpheniramine, methadone, normethadone and ephedrine. As a
result, the medication that she accidentally ingested were sent for qualitative and quantitative analysis and
was compatible with the urine results. Hence the patient suffered from liver failure due to paracetamol
overdose complicated by hypoglycaemia and seizure. Narcotics, anticholinergics and anti-inflammatory
drugs might contribute to the clinical presentation of the patient. The child remained sleepy, with episodic
hypoglycaemia requiring repeated infusion of dextrose solution. The paracetamol level and liver enzymes
started to decrease after the NAC.
After stabilizing her condition, she was transferred to PICU for further treatment and monitoring.
She was assessed regularly for further signs of Acetaminophen toxicity, NVS monitored hourly, urine and
stool output especially the stool color every shift is monitored. Bleeding not noted. Subsequent ABG and
Acetylcysteine level are normal. The following day Milk formula was resumed as patient is stable and
crying for milk. Course in the ward is uneventful and discharged after 5 days of hospitalization to
continue her milk formula, and Multivitamin 1 tsp OD. Paracetamol 120 mg/5ml 1 tsp as PRN for fever.
Latest V/S= T-36 degree Celsius, PR 90 beats/ min, RR 26 cpm B/P 90/60 mmHg and O2 Saturation of
97%. ss. Mother and significant others counselled prior to discharge.

Study Questions:
1. What is Acetaminophen Poisoning? What are the predisposing factors that may cause its
occurrence? What may be the reasons for the patient to acquire this condition?
2. Determine the organs that were affected by the patient’s condition. What were the effects on these
organs?
3. Present the pathophysiology of the patient’s condition leading to Acetaminophen Poisoning
basing on the situation. Present this in a diagram and discuss thereafter.
4. Identify the signs and symptoms presented by the patient and correlate this to the
pathophysiology.
5. What are the necessary diagnostic tests and procedures which determined the condition of the
patient?
6. What were the specific diagnostic tests that the patient has undergone? Present results that
correlate/ identify his condition and discuss the significance.
7. What has been done to the patient to treat his condition? Identify and discuss specific
managements that were done to the patient.
8. What were the medications given to the patient? Identify and discuss specific medications for
treating the patient.
9. Transcribe the treatment and record to the appropriate monitoring sheet
10. Make a Nursing Care Plan for the management of the patient. Present appropriate nursing
diagnoses as bases for planning and intervention.
11. Make a continuing management plan to improve the patient’s condition.
12. Discuss your role as a nurse to educate the public on how to prevent/ avoid all sorts of poisoning.
Identify the different antidotes of commonly identified poisoning agents