Presentation on theme: "Clinical Pathological Case Presentation NACCT 2003 Jerry D. Thomas, MD Georgia Poison Center Emory University School of Medicine."— Presentation transcript:
Clinical Pathological Case Presentation NACCT 2003 Jerry D. Thomas, MD Georgia 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 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:
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 marijuana Percodan Demerol Amphetamines Myriad 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,hypnotic Used by Elvis Causes NCPE when injected not usually when taken orally After IV injection causes a minty taste in the mouth then dyspnea Abbott discontinued production in 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: Conces, DJ, et al. Pulmonary edema induced by intravenous ethchlorvynol. Am J Emerg Med 1986;4: Glauser FL, et al. Ethchlorvynol (Placidyl) – induced pulmonary edema. Ann Intern Med 1976;84: Burton WN, et al. Adult respiratory distress syndrome after Placidyl abuse. Crit Care Med 1980;8: Swearingen PV. Placidyl and pulmonary edema. Ann Int Med 1976;84: Yell RP. Ethchlorvynol overdose. Am Journ of Emerg Med 1990;8:
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):
Other guesses Talc emboli Marijuana contaminant Just about anything