Paraquat poisoning, an emerging problem, a challenging outcome

Kalaiyarasi¹,*, BabiyoReni²

¹Nursing Supervisor, Kauvery Hospital, Tennur, India

²Staff Nurse, Kauvery Hospital, Tennur, India.

Abstract

Paraquat is a herbicide of great toxicological importance. Paraquat poisoning is an emerging problem, and the mortality rate of patients with severe paraquat poisoning is extremely high. Paraquat causes great damage to human organs through the destruction of kidney, liver and lung function. Especially in the lung, it can cause lung fibrosis with hypoxia and respiratory failure, one of the major causes of death in the patient. After oral intake of paraquat, it is quickly absorbed across the gastrointestinal mucosa and its blood circulation and is actively transported into cells. The lungs are its main target organ. Paraquat triggers alveolar interstitial infiltration by a large number of inflammatory cells, which cause acute lung injury in the early stage and results in lung fibrosis in the advanced stage which is the main cause of death of patients. Liver and kidney damage in patients can jointly lead to multiple organ failure.

There is currently no specific treatment and there is no specific antidote for paraquat poisoning. Only nursing care can improve the patient’s outcome and that includes early assessment, early gastric lavage, oral administration of activated charcoal, excretion of paraquat accelerated by early hemoperfusion, and other supportive measures such as early psychological care, early nutrition support, respiratory care and monitor of liver, kidney function, etc. In this article we would like to share our best nursing care practices that helped in recovering patient from paraquat poisoning.

Case Presentation

A 36 years female had an argument with her husband over a family matter. She brandished the poison which spilled over her face; she ingested and inhaled some amount of poison. She was taken to an outside hospital where she was treated as an inpatient later referred to Kauvery Hospital, Tennur, for further management. She was known to have hypothyroidism for which she was not taking regular treatment.

On arrival, the patient was conscious and oriented, afebrile, PR: 96/min, BP: 110/70 mm Hg, SpO2: 98% in room air, CVS: S1S2 (+), RS: bilateral NVBS, P/A: soft.

Anesthetist opinion was obtained and she was started on intravenous fluids, N- Acetylcysteine (the mainstay of therapy for acetaminophen toxicity), Vitamin C, proton pump inhibitors, antiemetics and antacids were administered. Also, the doctor explained the condition to the attenders that she has been exposed to a high level of danger, with a mortality of 90%. Possibility of renal and liver failure, need for mechanical ventilation, pulmonary fibrosis etc were explained to the patient’s husband. Necessary investigations were carried out.

A nephrologist opinion obtained for borderline elevated RFT and decreased urine output, and treated conservatively.

Medical gastroenterologist’s opinion obtained for abdominal pain, and LFT elevation; treated with PPI and started TPN (total parental nutrition). Oral liquids were started on D4 of poisoning.

ENT opinion was obtained for throat pain and managed conservatively.

An ophthalmologist opinion was obtained for ocular irritation. She advised antibiotics and refresh tears eye drops and treated conservatively.

Dermatologist opinion obtained for spillage of poison over face and treated conservatively with soframycin ointment.

A psychiatrist’s opinion was obtained and provided counselling to the patient.

The patient shifted to intensive care and continuous monitoring was done.

The patient showed good recovery; general conditions were good. Saliva secretions were slightly reduced, nausea reduced, and vomiting stopped. The patient was shifted to the ward, and as the patient’s condition improved, vitals became stable, and was responding well, she was discharged with instructions for care at home.

Diagnosis

Paraquat poisoning

Hypothyroidism

Relevant investigation

Urea: 32 mg/dL, Creatinine: 0.86 mg/dL, Bilirubin: 0.58 mg/dL, INR: 0.27, Sodium: 3.2 mmol/L.

X-ray and USG abdomen were taken reports were normal. ECG taken. Normal sinus rhythm.

Medication

Tab. Taxim O	200 mg	1-0-1 × 5 days
Tab. Metrogyl	400 mg	1-1-1 × 5 days
Tab. NAC	600 mg	1-1-1 × 5 days
Tab. Vitamin C	500 mg	1-1-1 × 5 days
Tab. Pan	40 mg	1-0-1 × 5 days
Tab. Emeset	4 mg	1-0-1 × 5 days
Syp. Mucaine	15 ml	1-1-1 × 5 days
Syp. KCL	10 ml	1-1-1 in one glass of water × 5 days
Refresh tears eye drops		1-1-1-1
Gentamicin gel		0-0-1
Soframycin ointment		1-1-1 x all for 1 week

Nursing management

Nursing care is one of the major components of health care services. As a nurse, we spend more time with a patient than anyone else in the healthcare facility. Provided bedside services which includes quality, safety, comfort, calm environment after explaining to the patient and attendants.

Hemodynamic monitoring

After receiving from casualty our critical care team had a discussion regarding Patients with paraquat poisoning who should be monitored for the development of mucosal injury, acute renal failure, liver injury, and respiratory failure. The most damaging clinical effect of paraquat poisoning is pulmonary toxicity, leading to pulmonary fibrosis and respiratory failure. Our team aggressively monitored this patient. Q2H re-assessment done through the invasive and non-invasive methodology. Noninvasively, we monitored the patient BP, pulse rate, rhythm, skin temperature, skin colour, capillary refill time, oxygen saturation, mentation, urine output etc. Invasively we monitored cardiac output, tissue perfusion and ABG analysis by means of an arterial catheter. ABG gave a clear picture on the response to the treatment such as drugs and oxygen support. Through all this, we had managed proactively to show a good outcome. Since our patient did not go for any organ dysfunction the removal of paraquat-toxins from the blood was not performed through Hemo perfusion (HP). After stabilization in the critical care unit shifted to the ward. There his vitals were monitored Q4h which was uneventful.

Communication

Patient information was effectively communicated in a language that they can understand. The staff applied the communication tool ISBART for clinical communication and AIDET effectively to improve communication and maintain a good rapport with patients and attendants. At the time of starting shift nurses used to introduce themselves and explain the patient’s general condition, nursing process related to diet, medication, doctor rounds, investigations report etc. to the patient using AIDET tool. Though the doctors were communicating the prognosis to the patient attendants, they insist on the nurses explaining in detail as they were hesitant to ask the doctor.

Preventive aspects of nursing care

This patient has stayed for more than 10 days and undergone many invasive lines like arterial lines, Hemo Dialysis catheters, urinary catheters, and multiple peripheral lines. It was a challenge for nurses to prevent HAI in spite of all invasive lines. Bundle care practices were strictly adhered to and achieved the best outcome of No CLABSI, No CAUTI, no pressure injury throughout the hospital stay also no NOSOCOMIAL infections.

Our team has done risk assessment in each shift and done planning and implemented all the preventive measures like FALL, DVT, Delining of tubes, and pressure injury Our nurses adhered to Antibiotic Policy etc.,

We ensured free from infecting and adhere to various tools for the preventive aspects of care like Morse Scale, Wellí¢€â„¢s Criteria, Braden Scale etc to ensure patient quality.
Our team has effectively followed International Patient Safety Goals 1-7 for the preventive aspects of care to ensure patient safety.
We have adhered to FASTHUGSBID in critical care units and inwards for the preventive aspects of care. F-Feeding/Fluids, A-Analgesia, S-Sedation, T-Thromboprophylaxis, H- Headup position, U- Ulcer prophylaxis, G-Glycemic control, S-Spontaneous breathing trial, B- Bowel Care, I-Indwelling catheter removal, D-Drug de-escalation.
Based on this patient condition we set the clinical alarm in multi para monitor and if the alarm indicates any deviation in vital parameters immediately, we respond the alarm and done reassessment and proactively managed accordingly and prevented major complication.

Nutrition

Any patient to come out of their illness the nutrition part is so important also this patient had severe oral ulceration we had a challenge in the administration of feed. Nurses are focused on patient nutrition along with the doctor, and dietitian to avoid hypoglycemia, nutritional deficiency etc. Our team has taken challenge and provided good nutrition with adequate calories and supported with IV fluids

Personal hygiene

Personal hygiene is necessarily maintained for a personí¢€â„¢s comfort and well-being. Our Nurses assessed the patient’s regular oral hygiene, mobility, ambulation, toileting, personal care and hygiene, grooming, dressing, brushing, bathing and eliminating,

Psychological support

By explaining the poor prognosis and poor outcome of the disease, the patient and the attendant were worried they got depressed, to bring out their emotional depression, our team has given emotional and psychological support to the patients, and family member, provided best communication and coordination with other team members, so the patient health has improved and attained the possible outcome.

Discussion

Paraquat is a toxic chemical that is used for weed and grass control. In the United States, paraquat is available primarily as a liquid in various strengths. Deliberate self-poisoning with pesticides such as paraquat continues to be a problem in the United States and abroad. Therefore, awareness and education of health professionals about the serious consequences of exposure to paraquat and a general understanding of treatment are important. In the U.S. paraquat has “restricted use” and can only be used by licensed applicators. In our case, the patient was a farmer and that enable him to receive paraquat access through his line of work. Because of the high toxicity of paraquat, the form marketed in the United States has security features such as a blue dye, sharp odour, and an emetic agent. These characteristics are similar to the fluid that our patient reported ingesting, making our suspicion of actual paraquat ingestion stronger.

Conclusion

As there is no specific clinically proven antidote for paraquat poisoning, supportive treatment is given. This case demonstrates now that all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis and clinicians. Specialists, and nurses all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members.

As per the doctor’s orders antibiotics, investigations and treatment were carried out through the best nursing care. The patient continued to improve, received psychiatric evaluation and treatment, and eventually made a full-recovery. He was discharged on hospital day ten with intensive psychiatric treatment related to his suicide attempt and health education for the care at home.

“Nursing Care is the best Antidote for Paraquat Poisoning

Nursing Care is the only Antidote for Paraquat Poisoning

Nursing Care become an Antidote for Paraquat Poisoning

Antidote for Paraquat Poisoning!! (Is Nursing Care)”

Paraquat poisoning, an emerging problem, a challenging outcome