Clinical Pathological Case Presentation
NACCT 2003
Jerry D. Thomas, MDGeorgia Poison Center
Emory University School of Medicine
What We Know
CC: Dyspnea
HPI: History of IVDA Progressive dyspnea for 2 days No fevers, chills, cough or chest pain Treated for PCP with TMP/SMX and transferred Denies recent cocaine, heroin, or methamphetamine Took 2 carisoprodol tablets in last 24 hours Took “the shit that killed [rock star]”
What We Know
PMH Previously healthy Rehab admissions HIV negative one year ago Known 2 carisoprodol, TMP/SMX
What We Know
Social History Unemployed and lives with girlfriend Smokes 1 ppd cigarettes and marijuana IVDA cocaine, heroin, and methamphetamine
Medications and Allergies None
What We Know
Physical Exam Afebrile Tachycardic and tachypneic Hypoxic
O2 saturation 82% on RA and 91% on 100% NRB Abnormals
RR-30
What We Know
CV – Tachycardic but no rubs or murmurs (gallop?)
Neck - ? JVD
Lungs – Diffuse rales bilaterally
Extremities – Track marks in the left antecubital fossa and tattoos on chest and arms
What We Know
Labs WBC: 15.9 k/mm3
HCT: 45.0 % Platelets: 240 k/mm3
Differential59.9% Neutrophils26.3% Lymphocytes6.2% Monocytes
What We Know
Labs NA 138 meq/L K 4.6 meq/L CL 105 meq/L HCO3 23 meq/L BUN 12 mg/dL Cr 0.7 mg/dL Glu 141 mg/dL Ca 8.6 mg/dL
What We Know
Labs ABG on Room Air
pH 7.4 pCO2 34 mmHg pO2 46 mmHg HCO3 23 meq/L
ECG Sinus tach, QRS 88 ms, QTC 390 ms, no ectopy or
ischemia
What We Know
Urine Drug Screen Amphetamines – Negative Cocaine – Negative THC – Positive Benzodiazepine – Negative Barbiturates – Negative TCAs – Negative
ASA/APAP/ EtOH Nondetectable
What We Would Like To Know!
Better physical exam
Clinical course prior to presentation
Cardiac echo
CVP
When did he last use his usual drugs?
What type of DOA screen
Which freaking rock star!!!
Clinical Picture Due to:
Noncardiogenic Pulmonary EdemaCardiogenic Pulmonary Edema/Myocardial Infarction/Cardiomyopathy/Endocarditis/Valve or leaflet ruptureAspiration PneumonitisToxic InhalantsMyocardial Depressant Effects of ToxinTalc Emboli
Developing a Differential
Pulmonary Edema Cardiogenic Noncardiogenic
Drugs of Abuse
Rock Stars
Systems Analysis
Rock Star Deaths
Pulmonary Edema Drug Abuse
Cardiogenic versus Noncardiogenic Pulmonary Edema (NCPE)
Cephalization of Pulmonary Vessels
Cardiomegaly
Pulmonary Capillary Wedge Pressure > 20 mm Hg
NCPE sometimes classified with ARDS
Cardiogenic Pulmonary Edema
Acute Poisoning
Adrenergic Agonists -Myocardial Infarction Ergotamines Cocaine Amphetamines Ephedrine
After Mark Kirk CPC NACCT 2000
Cardiogenic Pulmonary Edema
Acute Poisoning
Carbon Monoxide
Arsenic
Antineoplastic Agents Interferon Cyclophosphamide Anthracycline
Cardiogenic Pulmonary Edema
Chronic ExposureIpecacEthanolThiamine/Carnitine/Selenium DeficiencyHypophosphotemiaCobalt Doxorubicin
Cardiogenic Pulmonary Edema
Acute PoisoningCalcium Channel AntagonistsBeta-Adrenergic AntagonistsSodium Channel Blockers Type IA antidysrhthmics Amantadine/Antihistamines TCA/Quinine/Chloroquine Cocaine/Propoxyphene
Pulmonary EdemaMedicinal: aldesleukin, amantadine, amiloride, amiodarone, ammonium chloride, bleomycin, boric acid,
buflomedil, carteolol, chlorhexidine gluconate, chloroxylenol, cocaine, codeine, colchicine, cytarabine, desipramine, dibenzepin, dipyridimole, doxepin, esmolol, ethchlorvynol, glutethimide, haloperidol, heroin, imipramine, iodine, iron, ketorolac, lindane, methadone, methamphetamine, methyprylon, minoxidil, morphine, nalbuphine, naproxen, nifedipine, nimodipine, nitrofurantoin, nortriptyline, opium, oxycodone, paclitaxel, paraldehyde, pentazocine, phenobarbital, phenol, phenolphthalein, phenylbutazone, pilocarpine, povidone-iodine, propofol, propoxyphene, propranolol, protamine, rifampin, ritodrine, sodium chloride, sotalol, tenecteplase, terbutaline, tocainide, verapamil, vinorelbine, zinc sulfate
Nonmedicinal: 1,2-dibrom-3-chloropropane, dibromoethane, acetaldehyde, acrolein, aldicarb, aluminum phosphide, ammonia, benzene, blasticidin s, bromophos, carbaryl, chenopodium oils, chlorfenvinphos, chlorine, chloracetophenone, chlorobenzylidene malonitrile, chlorform, chloropicrin, chlorpyrifos, copper, coumaphos, cresols, cyanide, demeton-s-methyl, diazinon, diborane, dichlorvos, dicrotophos, diethylene glycol, dimethylnitrosamine, dioxathion, disulfoton, endosulfan, ethion, ethylene dichloride, ethylene glycol, ethylene oxide, fensulfothion, fenthion, freon, gasoline, hydrazine, hydrogen chloride, hydrogen fluoride, hydrogen sulfide, jet fuel-5/jet fuel-8, malathion, mercury, methidathion, methiocarb, methomyl, methyl bromide, methyl parathion, nickel, nickel carbonyl, nitrogen dioxide, osmium, parathion, phosdrin, phosgene, phosphine, profenofos, propoxur, pyrethrins, selenium, sodium azide, sulfur dioxide, sulfuryl fluoride, terbufos, tetraethyl pyrophosphate, thallium sulfate, titanium, toluene, trichloroethane, trichloroethylene, trimellitic anhydride, turpentine oil, uranium, vanadium, zinc phosphide
Biologicals: Arizona bark scorpion, autumn crocus, betel nut, box jellyfish, clove, eucalyptus oil, funnel web spider, germanium
What Causes Pulmonary Edema?
What doesn’t cause pulmonary edema?
Etiologies of NCPE
Direct Injury Aspiration Inhalational injuries Near drowning Pulmonary contusion Diffuse Pulmonary infection
Perina DG. Noncardiogenic pulmonary edema. Emerg Med Clinics of NA 2003;21:385-393.
Noncardiogenic Pulmonary Edema
Adult Respiratory Distress SyndromeOpioids/NaloxoneSalicylatesIrritant GasesAmphetamines/ CocaineThiazide DiureticsAmiodarone/ Amphotericin/ Vinca Alkaloids/ Colchicine/ Ethchlorvynol
Indirect Injury
Systemic Sepsis and septic shockBlood products transfusion reactionHigh altitude effectsDrug overdoseNeurogenic insultsPancreatitisCardiopulmonary bypassSevere non-thoracic traumaFat emboliAir emboli
Indirect Injuries
Uremia
Coagulopathies
DIC
Common drugs
Drug OD Heroin Methadone Aspirin Propoxyphene Ethchlorvynol
Reed CR, et al. Drug-Induced Noncardiogenic Pulmonary Edema. Chest 1991;100:1120-1124.
NCPE
Inhaled toxins Smoke Ammonia Chlorine Nitrous oxide Phosgene Methylene chloride
Rock Star Deaths
Where did I keep those notes from Erickson’s lecture? Heroin
Tommy Bolin, Sid Vicious, Janis Joplin, Billie Holliday, Dee Dee Ramone, Lance Krantz, Jan McAdam, Paula Yates, Eddy Shaver, Will Clay, Stacy Guess, Brad Nowell, Frankie Lymon, Neil Storey, Gregory Herbert, Judee Sill, Rick Evers, Roy Montrell, Danny Whitten, Dave Waller
Cocaine Shannon Hoon, Wells Kelly, DJ Screw, Bobby Sheehan, Tommy Bolin, David Ruffin
Barbiturates Jimi Hendrix, Judy Garland, Brian Epstein
Amphetamines Hank Williams
Other Zac Foley, Rob Pilatus, Elvis Presley, Keith Moon
I need an Atypical Rock Star Death
Everything this guy usually takes could cause this!
UDS negative for opiates, cocaine and amphetamines ? False negatives
Synthetic opiate
Keith Moon Heminevrine- Chlormethiazole being used for EtOH
addiction.
Screw It
Differential too large
I’ve got better things to do
I’m not feeling the love
I need a new system approach
EKR Systems Approach to CPCs
Apologies to Dr. Elizabeth Kubler-Ross
Denial
I am good enough and smart enough and doggone it, people like me.
I have plenty of time to figure out the CPC!
Anger
How the hell do they expect me to figure out this CPC!
Everything has a case report associating it with pulmonary edema!
Where are my fellows when I need them!
Bargaining
Who can I bribe to figure out this CPC?
How can I cheat if at all possible?
Depression
My differential just keeps getting larger.
Maybe there will be another blackout.
What do 4 out of 5 toxicologists recommend for an overdose?
Acceptance
OK, the differential is enormous and there is little to narrow down the field so what answer is the most satisfying intellectually for an NACCT CPC?
What Would Elvis Do?
What didn’t Elvis do?
The Shit That Killed Elvis
Elvis died in the bathroom.Slang term for high grade marijuanaPercodanDemerolAmphetaminesMyriad sedative hypnotics Methaqualone Barbiturates Ethchlorvynol
Marijuana
UDS positive for THC Doesn’t usually cause pulmonary edema Possible contaminant
PCP Ketamine Paraquat
Methaqualone
Used by Elvis
Reports of Pulmonary Edema
Schedule I since 1984 and reports are infrequent
Kids are making everything these days
Ethchlorvynol
Placidyl – sedative,hypnoticUsed by ElvisCauses NCPE when injected not usually when taken orallyAfter IV injection causes a minty taste in the mouth then dyspneaAbbott discontinued production in 1999.Is it available?
Ethchlorvynol
The following ethchlorvynol cases have been reported to AAPCC TESS since 1/1/2000:
50 human cases as substance 1, no deaths
90 human cases total as one of the involved substances, no deaths
Does it Fit?
Miller, KS, et al. Bilateral exudative pleural effusions following intravenous ethchlorvynol administration. Chest 1989;95:464-465.
Conces, DJ, et al. Pulmonary edema induced by intravenous ethchlorvynol. Am J Emerg Med 1986;4:549-551.
Glauser FL, et al. Ethchlorvynol (Placidyl) – induced pulmonary edema. Ann Intern Med 1976;84:46-68.
Burton WN, et al. Adult respiratory distress syndrome after Placidyl abuse. Crit Care Med 1980;8:48-49.
Swearingen PV. Placidyl and pulmonary edema. Ann Int Med 1976;84:614-615.
Yell RP. Ethchlorvynol overdose. Am Journ of Emerg Med 1990;8:246-250.
Treatment
Supportive Care PEEP Usually resolves within 72 hours
Animal studies did show possible benefit in pretreatment with cyclooxygense inhibitors
Nesiritide Bobadilla RV, et al. Nesiritide treatment of
noncardiogenic pulmonary edema. Annals of Pharmacotherapy. 2003;37(4):530-533.
Other guesses
Talc emboli
Marijuana contaminant
Just about anything