TYLENOL OVERDOSE

It was a busy day in the E.R. and it was already 1600. I had four monitored beds as my assignment. I just brought a patient up to the telemetry floor when I saw Sharon wheeling a young girl down the hallway with her mother quickly following behind. She was heading towards my open monitored bed. I grabbed a clipboard and my nurse’s notes and walked over to the bedside. The young girl did not appear to be in any noticeable distress. She actually looked more upset at her mother than anything medical. Her mom looked upset with her but I could tell she was caring of her daughter. As I approached Sharon closed the curtains around bed 10. The young girl and mother were on the other side. “She is getting into one of our gowns,” Sharon told me as she walked towards the nurse’s station. I followed her to get the history of my new young patient. “What’s going on with here?” I asked. “Her name is Melissa. She is 15-years-old and got mad at her mom yesterday early afternoon because she could not go out with her friends because she was grounded,” said Sharon. I had a feeling where this was going but continued to listen. “Melissa decided to get back at her mother by taking a bunch of Tylenol. She could not tell me how many she took,” Sharon said. “Why is she here now instead of yesterday?” I asked. “Well, Melissa just told her mother ten minutes ago what she had done before her mother dragged her into the emergency room.” I got a sick feeling in my stomach. This was a scenario I had seen too many times. “Okay,” I told Sharon as I walked over to bed 10.  

I walked over to my new young patient in bed 10. I grabbed my IV and blood drawing equipment because I knew we would at least need to draw a Tylenol level and liver function tests. I knew Melissa had to be dressed in the gown by now. “Are you dressed yet?” I asked outside the curtain. I knew a 15-year-old needed privacy as she dressed. “Yeah,” I heard. I peeked my head around the curtain to see Melissa sitting on the stretcher with her arms crossed over her chest. Her mother was standing next to her obviously upset with her daughter’s decision to take a bunch of pills because she could not go out with her friends. Melissa had obviously been crying. How hard it was to be a teenager. What Melissa did not understand was she could have serious medical consequences taking an overdose of Tylenol. What made it worse was she waited over 24 hours to tell her mother which could further cause problems with her young liver. I placed my blood tubes and IV starting equipment on the supply cart located at the head of the stretcher. Melissa watched me as I set my equipment down. I walked next to the stretcher and placed the blood pressure cuff on her right arm. “I need to get your blood pressure and pulse,” I told her. She knew she needed to be tolerable because her mother was standing next to her. “Do you know how many Tylenol you took yesterday?” I asked. Melissa continued to sit on the stretcher with her arms crossed. “Tell her!” her mother said. “I don’t know. It was a handful I guess. Maybe about 60 pills or so,” Melissa said. Her mother looked at her and a tear formed in her eyes. Her mother knew how detrimental her daughter’s decision could become. “Did you take anything else with the Tylenol?” I asked. “No. Just the Tylenol,” said Melissa. She still had her arms folded over her chest. I hooked up the cardiac monitor. I knew Melissa would be going to the intensive care unit because she was a Tylenol overdose. Her Tylenol level would dictate how much she took and how serious her situation would become. Melissa could have significantly damaged her liver. “Why did you take the Tylenol?” I asked. Melissa was silent. I stood patiently at the bedside and looked at her with a nonjudgmental face. Finally she started to tell me her reasons for taking a bunch of pills. “I got mad at my mother because I wanted to go out with my friends,” Melissa said. “I knew it wouldn’t be a big deal because you can buy the stuff at the grocery store,” she said. “Melissa. Taking a lot of Tylenol can permanently damage your liver. This is serious,” I replied. She remained with her arms folded over her chest. She did not understand the seriousness of her decision to get back at her mother. “I need to get some blood from you,” I told her. Her arms unfolded because the thought of a needle was worse than taking the pills. “Why? I mean I just took a couple of pills!” she screamed. “Melissa. Taking a lot of Tylenol can kill you,” I told her. Melissa and her mother looked at me. Melissa then got a scared look on her face. “How can it hurt you when you can buy it at the grocery store?” Melissa replied. “It can be a serious drug if you take too much of it. Just because you can buy it at the grocery store does not mean it cannot harm you.” I took about 15 seconds. “Do you have any pain right now?” I asked. “Well. A little right here,” she said as she pointed to her upper right quadrant. “How about the feeling like you want to throw up?” I asked. “No. Well, a little. But I haven’t,” she replied. Her mother started to cry quietly. She sat down on the chair next to Melissa. “I need to get an IV in you and some blood. This is serious Melissa.” I proceeded to get my equipment together to start her IV. Melissa and her mother were speechless. I felt for the both of them. Her mother thought she was doing the best for her daughter by grounding her and Melissa thought she would get back at her mother by taking a bunch of pills.

Melissa allowed me to get a 20 gauge IV catheter in her left forearm and draw the blood. As I was taping up the IV and extension tubing Dr. Phillips walked into the area. He needed to do his assessment before ordering the blood work and medication. I looked up at the cardiac monitor and it read sinus tachycardia at a rate of 102. I knew this was because she was upset with her mother and now the fact she may have harmed herself from taking too much Tylenol. Her blood pressure was 102/56. I set the vitals to re-take every 30 minutes. I labeled the tubes of blood with the time, date, and my initials on the sticker. I needed to put the blood tubes aside and wait for Dr. Phillip’s orders. I hoped Melissa’s Tylenol level was not high but had a gut instinct it probably was. It upset me how such a good medication could turn into something very serious. Teenagers as well as adults did not understand the significance of taking too much of any medication whether it was over-the-counter or prescription.

Dr. Phillips ordered a comprehensive metabolic panel which included electrolytes and liver function tests. He also ordered an acetaminophen level as well as a urine drug screen. Maybe Melissa took other drugs on top of the Tylenol. Mucomyst was ordered for Melissa to drink. Mucomyst was a very smelly medication which was difficult for patients to drink. I knew Melissa would probably not want to drink the smelly stuff so I needed to think of a way to get it down. Mucomyst binds with the Tylenol and is excreted in the stool. I was concerned because Melissa had waited too long but hoped some of the Tylenol would bind to the medication. I walked over to bed 10. “What kind of soda or juice do you like to drink?” I asked Melissa. “Coke usually,” replied Melissa. “Okay,” I said as I walked towards the nurse’s station. There would be a lot of Mucomyst to get down Melissa and I wanted to make sure she got every drop to try to prevent liver damage. I called the pharmacy to get the required dose. Melissa would be drinking a lot of smelly Coke.

I proceeded to mix the Mucyomyst with the Coke. Although it looked like Coke it did not smell like it. “Boy this stuff stinks,” I said to Chuck in the med room. “Tell me about it. I can smell it from here,” he replied. I brought the smelly Coke to Melissa’s bed. “You need to drink this and all of it,” I told her. Melissa took one sniff of the concoction and told me “no way.” “If you want me to mix it with something else we can give it another try. But you need to drink it,” I responded. She looked at me and her mother. I really hated the thought of lavaging her to get it in her stomach. Lavaging took a large plastic tube which went down a patient’s throat into their stomach. This was considered “pumping the stomach” when somebody overdosed. Not a pleasant experience but was necessary to help the patient from harming themselves. Melissa decided it was best to drink the smelly Coke. She made faces as it went down. I told her this was only the first drink. There would be many more before she got the amount of medication she needed. Melissa looked at me and her mother. She took her hand and plugged her nose as she drank the Coke. I think she finally realized her decision over 24 hours ago was not the best. I needed to find out what her Tylenol level was. I hoped it was not too high and she would have a good outcome. Afterall, she was just an emotional teenager wanting to get attention and show rebellion towards her mother’s decision to ground her.

Melissa’s Tylenol level came back. It was 153mcg/ml. This was considered in the toxic range. Melissa may have damaged her liver and may have serious consequences regarding her health after taking too much Tylenol. She may even die a long and painful death if treatment did not work and the Tylenol damaged her liver beyond repair. Dialysis was also an option to get the medication out of her system. She will have her blood drawn every four hours to see what her acetaminophen levels were. Her liver enzymes AST and ALT were elevated. They may also rise after time. Melissa did damage to her liver after taking too much Tylenol. She was going to be admitted to the ICU for further evaluation. Melissa would be in the ICU for a while to determine the extent of liver damage. This was not the place for a 15-year-old girl.

Melissa was upset with her mother for grounding her. What Melissa did not understand was taking too much of an over-the-counter-medication could also have serious consequences. She had a long road ahead of her to determine whether she would do well or if she would have permanent damage to her liver. This could take months. Melissa was taken to the ICU where she would be for several days to determine how much liver damage was done from taking the Tylenol. I hoped it would not have been a fatal mistake. But time would tell Melissa’s fate. This was a 15-year-old girl taking a bunch of an over-the-counter medication to get back at her mother. How simple the teenager's thought process was but how serious the outcome of the thought process. It happened all too often. I hoped the best for Melissa and her mother. They had a long road ahead of them that could result in serious consequences because a teenager took a bunch of pills that were bought at the local grocery store.

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