- Email: [email protected]
Two Marines With Generalized Seizure Activity
CASE REVIEW
TWO MARINES WITH GENERALIZED SEIZURE ACTIVITY Authors: Lt Lalon Kasuske, RN, BSN, CEN, MBA, Lt Commander Joel M. Schofer, MD, and Kohei Hasegawa, MD, Okinawa, Japan Section Editor: Laura Criddle, MS, RN, CEN, CFRN
Earn Up to 8.5 CE Hours. See page 595.
J
ust before midnight, a 23-year-old active-duty Marine arrived via ambulance after having 2 generalized seizures at a local health center. The man presented to the clinic complaining of a headache, feeling “sick to his stomach,” and vomiting once. Witnesses reported that each seizure lasted approximately 2 minutes, with a 2-minute interval between episodes. On ED presentation the patient appeared to be in a post-ictal state, responding to verbal stimuli but generally confused and drowsy. His initial vital signs were as follows: blood pressure, 125/72 mm Hg; heart rate, 70 beats per minute; respirations, 14 per minute; and temperature, 36.6°C (97.9°F). Oxygen saturation was 100% on a nonrebreather mask. As he recovered from the seizures, our patient became increasingly coherent and was able to provide limited information. He denied having any previous convulsions but reported a long-term history of migraines. The man “felt fine” during the afternoon, which he had spent with a large group of Marines handling explosive ordnance. During that time his unit had been exposed to temperatures in the low 90s (F), with normal humidity relative to the summer season. The patient asserted that he had consumed an ade-
doi: 10.1016/j.jen.2008.05.001
quate amount of water, given the ambient temperature and humidity, and had eaten his normal intake of food. Prior to ED arrival, EMS personnel had established intravenous access, a normal saline solution bolus had been given, and the Marine’s fingerstick blood glucose level was measured as 94 mg/dL. He remained in normal sinus rhythm and was switched to 3 L of oxygen per minute via a nasal cannula. Seizure pads were prophylactically put in place on the stretcher. Approximately 15 minutes after ED arrival the patient was coherent enough for the staff physician to perform a detailed assessment. Physical examination of all systems was normal. The patient was alert, verbally responsive, and had no unusual neurologic findings. However, just as the physician was completing the examination, the patient experienced a generalized seizure. Administration of 15 L of oxygen was immediately restarted via a nonrebreather mask, and he was given 1 mg of intravenous lorazepam (Ativan). This protocol aborted the seizure after approximately 2 minutes. The patient was transported to the radiology department, with an emergency nurse escort, for a non-contrast computed tomography scan of his head. An additional 1 mg of intravenous lorazepam was required to manage agitation during the procedure. Following the examination, our patient was returned to the emergency department without further agitation or seizure activity. The computed tomography scan was interpreted by a radiologist as normal. While the Marine was out of the department, initial laboratory results became available, revealing several abnormal values. His white blood cell (WBC) count was 26,000/mm3 (reference range: 3.8-11 K/mm3), and creatine phosphokinase was 2151 milliunits/mL (reference range: 25-145 milliunits/mL). Urinalysis showed large amounts of blood and protein, but the urine drug screen was negative. The patient’s seizures and elevated WBC count prompted the physician to perform a lumbar puncture and order 2 g of intravenous ceftriaxone (Rocephin). Cerebral spinal fluid was positive for red and white cells, but the tap had been traumatic, making the results difficult to interpret. An internal medicine consultant ordered 1 g of phenytoin (Dilantin) and 1 g of vancomycin (Vancocin) to be administered via an intravenous line
542
JOURNAL OF EMERGENCY NURSING
Lt. Lalon Kasuske is Division Officer (Nurse Manager), Emergency Department, US Naval Hospital, Okinawa, Japan. Lt. Commander Joel M. Schofer is Staff Physician, Emergency Department, US Naval Hospital, Okinawa, Japan. Kohei Hasegawa is Japanese National Intern, Emergency Department, US Naval Hospital, Okinawa, Japan. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. For correspondence, write: Lt Lalon Kasuske, RN, BSN, CEN, MBA, Emergency Department, US Naval Hospital, PSC 482, FPO AP 96362, Okinawa, Japan; E-mail: [email protected]. J Emerg Nurs 2009;35:542-3. Available online 29 July 2008. 0099-1767/$36.00 Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
35:6 November 2009
CASE REVIEW/Kasuske et al
piggyback. A second 1-L bolus of normal saline solution was infused. As treatment continued for this patient, paramedics called the emergency department to report that they were transporting a second Marine with an acute onset of seizures. Patient No. 2 was a 19-year-old who was part of our first patient’s unit. The second man also had reported nausea and headache and presented to the same health clinic several hours after the original Marine had presented. As was the case with patient 1, patient 2 had no history of seizures, was adequately hydrated during the day, and had handled explosive ordnance within the past several hours. The second Marine arrived at the emergency department awake and alert and provided a history that illuminated the events surrounding both cases. The patients had ingested C-4 plastic explosive “on a dare” several hours prior to the onset of initial symptoms. Poison Control Center personnel were contacted, but no information regarding C-4 toxicity was available. Attempts to locate a Material Safety Data Sheet for the product also proved fruitless. Fortunately, an Internet search produced a wealth of information on C-4 ingestion; the topic has been well documented in the Annals of Emergency Medicine. Composition C-4 is a plasticized explosive containing 91% RDX (cyclotrimethylenetrinitramine), a highly explosive material, as well as small amounts of polyisobutylene (2.1%), motor oil (1.6%), and di-(2-ethyl-hexyl) sebacate (5.3%).1 When ingested or inhaled in sufficient quantities (calculated dose of 0.1 mg RDX/kg/day), dramatic clinical symptoms develop rapidly, including generalized seizures, gross hematuria, nausea and vomiting, muscle twitching, and changes in mentation.2-4 WBC count frequently rises within the first 12 to 24 hours following exposure. The intoxicative and seizure-producing effects of C-4 were first reported decades ago among factory workers during civilian development of the product in the United States.3 Today, C-4 is used widely for demolition and is a component of flares found in both civilian and military settings.5 During the Vietnam War, C-4 was used commonly for demolition blocks and was well known to service members as an agent capable of producing a euphoric reaction similar to that of ethyl alcohol.6 Numerous serious intoxications were attributed to C-4 throughout the Vietnam era, and more than 400 cases of seizure activity secondary to oral or respiratory absorption have been documented.3,4 Following ingestion or inhalation, C-4 metabolites produce central nervous system, renal, and gastrointestinal toxicity. Central nervous system manifestations, the most common symptoms, begin with confusion and progress to hyperirritability and seizure activity. Renal findings include oliguria, gross hematuria, proteinuria, and ele-
vated blood urea nitrogen levels. A review of the literature found no reported cases of seizure activity persisting more than 3 days following exposure, but RDX can be detected in stool and blood for as long as 6 days after ingestion.3 Management of C-4 intoxication consists primarily of supportive care, including airway management, gastric lavage (for recent consumption), and anticonvulsant therapy. Supportive care also involves monitoring urine output to detect the onset of acute renal insufficiency and maintaining normal fluid and electrolyte balance. Following ED stabilization, patient 1 was admitted to the ICU for further evaluation and observation. Patient 2 was transferred to a general medicine floor. Both Marines were discharged within a few days of arrival, with no apparent lasting effects from their C-4 ingestion. This case emphasizes the point that, when findings just do not add up and the clinical picture does not make sense, think toxicology. It is also a strong reminder that, regardless of the challenges encountered in an emergency department, the basics of nursing care remain relatively unchanged. Supporting a patient’s airway, breathing, and circulation—while providing symptomatic treatment and searching for reversible causes—remains the core of emergency nursing care.
November 2009 35:6
JOURNAL OF EMERGENCY NURSING
REFERENCES 1. Stone WJ, Paletta TL, Heiman EM, et al. Toxic effects following ingestion of C-4 plastic explosive. Arch Intern Med 1969;124: 726-30. 2. Burdette LJ, Cook LL, Dyer RS. Convulsant properties of cyclotrimethylenerinitramine (RDX): spontaneous, audiogenic, and amygdaloid kindled seizure activity. Toxicol Appl Pharmacol 1988;92:436-44. 3. Ketel WB, Hughes JP. Toxic encephalopathy with seizures secondary to ingestion of composition C-4. Neurology 1972;22:871-6. 4. Global Security.org. Explosives-nitramines. Available at: www. globalsecurity.org/military/systems/munitions/explosives-nitramines. htm. Accessed September 28, 2007. 5. Faust RA. Toxicity summary for Hexahydro-1,3,5-trinitro-1,3,5triazine (RDX). Chemical Hazard Evaluation Group, Oak Ridge National Laboratory; 1994. 6. Von Ottengen WF, Donohue DD, Yagoda H, et al. Toxicity and potential dangers of cyclotrimethylenerinitramine (RDX). J Industrial Hyg Toxicol 1949;31:21-31. This section features actual emergency situations with particular educational value for the emergency nurse. Contributions (4 to 6 typed, double-spaced pages) should include a case summary focused on the emergency care phase, accompanied by pertinent case commentary. Submit to: Laura M. Criddle, MS, RN, CEN, CFRN, Section Editor
Submit Case Reviews online at http://ees.elsevier.com/jen/
543
TWO MARINES WITH GENERALIZED SEIZURE ACTIVITY Authors: Lt Lalon Kasuske, RN, BSN, CEN, MBA, Lt Commander Joel M. Schofer, MD, and Kohei Hasegawa, MD, Okinawa, Japan Section Editor: Laura Criddle, MS, RN, CEN, CFRN
Earn Up to 8.5 CE Hours. See page 595.
J
ust before midnight, a 23-year-old active-duty Marine arrived via ambulance after having 2 generalized seizures at a local health center. The man presented to the clinic complaining of a headache, feeling “sick to his stomach,” and vomiting once. Witnesses reported that each seizure lasted approximately 2 minutes, with a 2-minute interval between episodes. On ED presentation the patient appeared to be in a post-ictal state, responding to verbal stimuli but generally confused and drowsy. His initial vital signs were as follows: blood pressure, 125/72 mm Hg; heart rate, 70 beats per minute; respirations, 14 per minute; and temperature, 36.6°C (97.9°F). Oxygen saturation was 100% on a nonrebreather mask. As he recovered from the seizures, our patient became increasingly coherent and was able to provide limited information. He denied having any previous convulsions but reported a long-term history of migraines. The man “felt fine” during the afternoon, which he had spent with a large group of Marines handling explosive ordnance. During that time his unit had been exposed to temperatures in the low 90s (F), with normal humidity relative to the summer season. The patient asserted that he had consumed an ade-
doi: 10.1016/j.jen.2008.05.001
quate amount of water, given the ambient temperature and humidity, and had eaten his normal intake of food. Prior to ED arrival, EMS personnel had established intravenous access, a normal saline solution bolus had been given, and the Marine’s fingerstick blood glucose level was measured as 94 mg/dL. He remained in normal sinus rhythm and was switched to 3 L of oxygen per minute via a nasal cannula. Seizure pads were prophylactically put in place on the stretcher. Approximately 15 minutes after ED arrival the patient was coherent enough for the staff physician to perform a detailed assessment. Physical examination of all systems was normal. The patient was alert, verbally responsive, and had no unusual neurologic findings. However, just as the physician was completing the examination, the patient experienced a generalized seizure. Administration of 15 L of oxygen was immediately restarted via a nonrebreather mask, and he was given 1 mg of intravenous lorazepam (Ativan). This protocol aborted the seizure after approximately 2 minutes. The patient was transported to the radiology department, with an emergency nurse escort, for a non-contrast computed tomography scan of his head. An additional 1 mg of intravenous lorazepam was required to manage agitation during the procedure. Following the examination, our patient was returned to the emergency department without further agitation or seizure activity. The computed tomography scan was interpreted by a radiologist as normal. While the Marine was out of the department, initial laboratory results became available, revealing several abnormal values. His white blood cell (WBC) count was 26,000/mm3 (reference range: 3.8-11 K/mm3), and creatine phosphokinase was 2151 milliunits/mL (reference range: 25-145 milliunits/mL). Urinalysis showed large amounts of blood and protein, but the urine drug screen was negative. The patient’s seizures and elevated WBC count prompted the physician to perform a lumbar puncture and order 2 g of intravenous ceftriaxone (Rocephin). Cerebral spinal fluid was positive for red and white cells, but the tap had been traumatic, making the results difficult to interpret. An internal medicine consultant ordered 1 g of phenytoin (Dilantin) and 1 g of vancomycin (Vancocin) to be administered via an intravenous line
542
JOURNAL OF EMERGENCY NURSING
Lt. Lalon Kasuske is Division Officer (Nurse Manager), Emergency Department, US Naval Hospital, Okinawa, Japan. Lt. Commander Joel M. Schofer is Staff Physician, Emergency Department, US Naval Hospital, Okinawa, Japan. Kohei Hasegawa is Japanese National Intern, Emergency Department, US Naval Hospital, Okinawa, Japan. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. For correspondence, write: Lt Lalon Kasuske, RN, BSN, CEN, MBA, Emergency Department, US Naval Hospital, PSC 482, FPO AP 96362, Okinawa, Japan; E-mail: [email protected]. J Emerg Nurs 2009;35:542-3. Available online 29 July 2008. 0099-1767/$36.00 Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
35:6 November 2009
CASE REVIEW/Kasuske et al
piggyback. A second 1-L bolus of normal saline solution was infused. As treatment continued for this patient, paramedics called the emergency department to report that they were transporting a second Marine with an acute onset of seizures. Patient No. 2 was a 19-year-old who was part of our first patient’s unit. The second man also had reported nausea and headache and presented to the same health clinic several hours after the original Marine had presented. As was the case with patient 1, patient 2 had no history of seizures, was adequately hydrated during the day, and had handled explosive ordnance within the past several hours. The second Marine arrived at the emergency department awake and alert and provided a history that illuminated the events surrounding both cases. The patients had ingested C-4 plastic explosive “on a dare” several hours prior to the onset of initial symptoms. Poison Control Center personnel were contacted, but no information regarding C-4 toxicity was available. Attempts to locate a Material Safety Data Sheet for the product also proved fruitless. Fortunately, an Internet search produced a wealth of information on C-4 ingestion; the topic has been well documented in the Annals of Emergency Medicine. Composition C-4 is a plasticized explosive containing 91% RDX (cyclotrimethylenetrinitramine), a highly explosive material, as well as small amounts of polyisobutylene (2.1%), motor oil (1.6%), and di-(2-ethyl-hexyl) sebacate (5.3%).1 When ingested or inhaled in sufficient quantities (calculated dose of 0.1 mg RDX/kg/day), dramatic clinical symptoms develop rapidly, including generalized seizures, gross hematuria, nausea and vomiting, muscle twitching, and changes in mentation.2-4 WBC count frequently rises within the first 12 to 24 hours following exposure. The intoxicative and seizure-producing effects of C-4 were first reported decades ago among factory workers during civilian development of the product in the United States.3 Today, C-4 is used widely for demolition and is a component of flares found in both civilian and military settings.5 During the Vietnam War, C-4 was used commonly for demolition blocks and was well known to service members as an agent capable of producing a euphoric reaction similar to that of ethyl alcohol.6 Numerous serious intoxications were attributed to C-4 throughout the Vietnam era, and more than 400 cases of seizure activity secondary to oral or respiratory absorption have been documented.3,4 Following ingestion or inhalation, C-4 metabolites produce central nervous system, renal, and gastrointestinal toxicity. Central nervous system manifestations, the most common symptoms, begin with confusion and progress to hyperirritability and seizure activity. Renal findings include oliguria, gross hematuria, proteinuria, and ele-
vated blood urea nitrogen levels. A review of the literature found no reported cases of seizure activity persisting more than 3 days following exposure, but RDX can be detected in stool and blood for as long as 6 days after ingestion.3 Management of C-4 intoxication consists primarily of supportive care, including airway management, gastric lavage (for recent consumption), and anticonvulsant therapy. Supportive care also involves monitoring urine output to detect the onset of acute renal insufficiency and maintaining normal fluid and electrolyte balance. Following ED stabilization, patient 1 was admitted to the ICU for further evaluation and observation. Patient 2 was transferred to a general medicine floor. Both Marines were discharged within a few days of arrival, with no apparent lasting effects from their C-4 ingestion. This case emphasizes the point that, when findings just do not add up and the clinical picture does not make sense, think toxicology. It is also a strong reminder that, regardless of the challenges encountered in an emergency department, the basics of nursing care remain relatively unchanged. Supporting a patient’s airway, breathing, and circulation—while providing symptomatic treatment and searching for reversible causes—remains the core of emergency nursing care.
November 2009 35:6
JOURNAL OF EMERGENCY NURSING
REFERENCES 1. Stone WJ, Paletta TL, Heiman EM, et al. Toxic effects following ingestion of C-4 plastic explosive. Arch Intern Med 1969;124: 726-30. 2. Burdette LJ, Cook LL, Dyer RS. Convulsant properties of cyclotrimethylenerinitramine (RDX): spontaneous, audiogenic, and amygdaloid kindled seizure activity. Toxicol Appl Pharmacol 1988;92:436-44. 3. Ketel WB, Hughes JP. Toxic encephalopathy with seizures secondary to ingestion of composition C-4. Neurology 1972;22:871-6. 4. Global Security.org. Explosives-nitramines. Available at: www. globalsecurity.org/military/systems/munitions/explosives-nitramines. htm. Accessed September 28, 2007. 5. Faust RA. Toxicity summary for Hexahydro-1,3,5-trinitro-1,3,5triazine (RDX). Chemical Hazard Evaluation Group, Oak Ridge National Laboratory; 1994. 6. Von Ottengen WF, Donohue DD, Yagoda H, et al. Toxicity and potential dangers of cyclotrimethylenerinitramine (RDX). J Industrial Hyg Toxicol 1949;31:21-31. This section features actual emergency situations with particular educational value for the emergency nurse. Contributions (4 to 6 typed, double-spaced pages) should include a case summary focused on the emergency care phase, accompanied by pertinent case commentary. Submit to: Laura M. Criddle, MS, RN, CEN, CFRN, Section Editor
Submit Case Reviews online at http://ees.elsevier.com/jen/
543