Have you ever had a drug seeker present with pulmonary edema

[DwayneEMTP]

No one ever said anything about anyone being a dumb medic student.

I never intended to imply that you did. I was hinting that I'd like you to justify your feeling that she was in trouble.

WTF? Thread after thread of complaining that the public doesn't know what a Paramedic is and Paramedics still can not identify other professionals correctly.

Second Who cares is she is a drug seeker?

So you are not going to answer our questions or anything. Just thanks I got what I needed???

Were more or less the entries I was referencing when speaking about the bitching...not a big deal. It simply seemed that the thread was going in a direction that wasn't all that positive...I wanted to hear more about this patient and didn't want to miss out on the opportunity in the case that Kaisu didn't want to contend with the attitudes.

It bothers me that students get offend and feel like they are being attacked. I never had that intent. I do feel like I was attacked for just asking questions.

What students were offended? I can't think where Kaisu referenced being offended by anyone. I took exception to the tone...made my point...and now am going to move on. If you reread your responses to her posts and feel that they were sincerly intended to share this educational experience with Kaisu and the rest of us, then I apologize if I've offended you.

There. Now hopefully we're all adequately consoled and can get back to learning what the heck was going on here. Until this thread I'd never heard the term 'narcotic induced pulmonary edema', but now that it's in my head I'd like to find a place to put it.

I hope all is well with everyone, life is treating you great, and look forward to a gazillion more spirited discussions in the future! :wink:

Dwayne

[DwayneEMTP]

Next clinical shift, I will try and find out more and I will post it here because you say you are interested. Please wait for it and I will get it for you.

For some reason this piqued my curiosity hard. I'd love to hear whatever you can find out.

I'm not going to research it until I hear more...see what we can figure out with the information we have in our brains so far...

Thanks Kaisu..

Dwayne

[Kaisu]

I googled this and found

http://www.chestjournal.org/cgi/reprint/72/2/230.pdf

pretty cool.

I know that this patient's diagnosis will likely be pulmonary edema caused by narcotic overdose because that was the diagnoses 4-5 weeks ago when she was admitted and intubated. The resolution was- as this article asserts - very fast and complete. She is under care of a pulmonary specialist who refuses to admit her to hospital unless/until she agrees to treatment by a pain management specialist - in our area, a euphemism for the guy that gets you off the narcs.

While there is no doubt that the lady's issue is real, she also learned that breathing difficulty is good for 2 - 3 days worth of the really good drugs. She was playing up the problem. I'll get the data from this visit to demonstrate it to you but I know this is what was happening.

Once again - thank you so much for your interest and input. I'm tickled because I thought it was pretty interesting and its nice to know you all think so too.

[Kaisu]

From ACP Medicine Online, Dale DC; Federman DD, Eds.

Acute noncardiogenic pulmonary edema can occur after administration of a number of drugs. Acute pulmonary edema can occur after intravenous injection of heroin or other narcotics. Because the edema fluid has a high protein concentration, it has been suggested that a permeability defect could be a pathogenetic factor, but this finding could result from a transient, extreme increase in capillary pressure produced by a so-called neurogenic mechanism. Onset usually occurs within a few hours after narcotic use, but occasionally, it may be delayed for as long as 24 hours. In addition to the clinical and radiographic features of pulmonary edema, typical signs of narcotic intoxication are present, such as pupillary constriction, decreased respiration, and altered mentation. Fever and leukocytosis do not necessarily indicate the presence of infection. As with neurogenic pulmonary edema, the primary differential diagnostic consideration is aspiration, because of the altered level of consciousness.

The OP patient had no signs of altered level of consciousness. She was alert, orientated and insistant that she needed something for the pain.

Management is supportive and should generally include intubation with mechanical ventilation, both to guarantee adequate ventilatory support and to provide airway protection against aspiration. The role of naloxone is uncertain. Certainly, a patient who has overdosed on narcotics and is experiencing life-threatening hypotension or bradycardia should be given naloxone. Likewise, if naloxone is given to an unresponsive and hypopneic patient who does not necessarily require mechanical ventilation for pulmonary edema, the patient may be spared intubation. In contrast, for a patient who is intubated on an emergency basis because of acute pulmonary edema and who becomes clinically stable without hemodynamic compromise, better management may be to allow the narcotic intoxication to reverse gradually rather than precipitously. There is no evidence that naloxone helps speed resolution of narcotic-induced pulmonary edema. In fact, naloxone has been reported to cause pulmonary edema.32 Furthermore, acute reversal of narcotic intoxication in a long-term addict could result in agitation, with marked sympathetic activation and a less stable clinical course.

This was exactly her treatment when she presented 5 weeks ago in severe respiratory distress. She was not given naloxon and her pulmonary edema resolved swiftly (first 12 hours). During her 3 - 4 day stay, she was scoped and investigated extensively, and given a lot of narcotics.

Cocaine causes acute pulmonary edema, usually when used as free-base cocaine. The pathophysiology is uncertain. Like heroin, cocaine leads to a high-protein pulmonary edema that suggests endothelial cell injury and increased capillary permeability. However, as has been suggested with heroin, cocaine could lead to extreme sympathetic activation with a steep, extreme increase in capillary pressure that could produce a transient increase in protein leakage across the capillary membrane. Cocaine also causes coronary vasoconstriction, with acute myocardial ischemia or infarction, resulting in pulmonary edema.

I will get the specifics on the patient in the OP after clinicals next week. I stand by my initial impression. She had mild respiratory distress, some pulmonary edema and it was brought on by her narcotic abuse. She came to the hospital hoping for more drugs.