A small group of five high school students were playing around in chemistry class after school to see how easy it is for terrorists to make chemical bombs and accidentally mixed up an organophosphate compound very similar to a nerve agent much like
the nicotinic-receptor poisons. They were found by the janitor who was cleaning up. He called 911 and they were all brought in to the ED, including the janitor, who also inhaled the fumes upon entering the room. Two of the five were exposed to the liquid, Jim and Don, when it overflowed, affecting their hands and arms. The other three, John, Tom, and Pete, inhaled the fumes. John was standing directly over the beaker while Tom and Pete were standing next to the beaker.
a. Who do you assess first? Does each have varying degrees of exposure? Triage these six clients according to their symptoms.
b. What is the treatment for this poisoning?
c. What is their prognosis and why?
d. Could this leak out into the community and become a chemical disaster? How?
Students' answers should include the following:
a. Before assessing these six victims or delegating assessment to other nurses in the ED, you must triage them according to their injuries. You find out the organophosphate compound was nicotinic in nature so you use the mnemonic for it. Jim and Don are contaminated with the liquid form as well as probable inhalation, needing red or immediate triage. The janitor inhaled as he entered and saw the casualties so he is also red but not as immediate as Jim and Don. Tom, Pete, and John are also red and immediate due to the nature of the chemical. Because exposure to vapor symptoms develops within a few seconds to minutes, with death as the end result if not immediately treated, all six must be in an immediate or red triage because time is life with this type of chemical disaster.
b. Treatment for this type of poisoning is atropine sulfate and pralidoxime chloride with Valium to control possible seizures. Atropine needs to be given every 5 to 10 minutes until breathing is under control and hypersecretion has ceased. Skin needs to be cleaned to remove all residual chemical with bleach and rinsed with plain water. Oxygen may need to be given for supportive measures for airway patency.
c. Prognosis for these victims depends on the route and
amount of exposure as well as the time from exposure to time of treatment. For those who had inhalation exposure, time from exposure to death could be as little as 10 minutes if antidotes are not administered. Those with dermal exposure only can have up to 18 hours to experience mild to moderate effects, again depending on how fast treatment is received.
d. Yes, by vaporizing into the air. Others may detect it has leaked into the community by noticing an atypical odor, and a low-lying fog in the area (see Box 15-4).
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