Podcast 1021: Pulmonary Edema From Naloxone Administration

0:00This is the emergency medical minute sponsored by CarePoint and HCA Health One. Yesterday, we had a pretty cool case of a guy that came in who was a Narcan wake-up. And you know, we see him in one of our deep pot rooms and you know, we're kind of watching and treating and just seeing how he does. And he just progressively kept on getting more and more hypoxic. And so, with that happening, are there any things that come to your eyes mind of like, what could be going on with this patient? Like, what are some options of what could be happening with a patient that, you know, we've administered Narcan to in the field. And then she come in, a little agitated, but awake, and then just have progressively worsening hypoxia. This patient ultimately got intubated and went to the ICU. So, aspiration is a great one. Yes, someone who's, you know, just imagine having an opioid overdose could have had, you know, an aspiration event and then like now kind of blossoming out on their lungs and now getting progressively hypoxia, for sure.

1:01That was one of the things that actually is still kind of possible that an patient might have had. So, aspiration is one thing. Does anyone have any other guesses of what might be going on? Just some other causes of hypoxia, maybe, even. So, one thing this person I also left out in an important detail, the person I think did get CPR in the field. Which, so we were thinking of possibly rib fracture and causing a pneumo. So, that was one thing that we were considering as well. Did a quick ultrasound, there was good lung sliding, X-ray also did not show anything, and then ultimately did get a CT, and it did not show any pneumothorax. But there's actually this complication that happens with administration of Narcan sometimes, and it's pulmonary edema. And yeah, it was a good catch, right? And she said it. You need to trust yourself. Yeah, so Narcan can cause pulmonary edema. And there have been different theories as to why, and some think that it like causes this neurologic,

2:03essentially mediated like catacol surge. But in recent years there's been new thinking that actually what happens, it's just a negative pressure event where someone is trying to breathe against their closed glottis, and that negative pressure causes pulmonary edema. So it's not like the Narcan is causing like a chemically related thing, but it's just like it's working, they're waking up, but they're trying to breathe, and their glottis is closed, and it causes pulmonary edema. So, looking at this patient's CT, he had pulmonary edema, and that's almost certainly what happened. So just for those patients, it's the same kind of thing you would do normally, so just positive pressure. We increase FIO2, we increase our peep, we keep on trying to toggle those values to try to improve their oxygenation. Interestingly though, they don't need diuretics, which you normally think of as pulmonary edema, because they're not really volume overloaded, it's not like too much extra fluid is the problem.

3:05So you just do supportive care, increased pressure, increased FIO2, this person ultimately kept the deteriorating, deteriorating, deteriorating, had to give more and more and more, we went from isolcanula, to non-mibreather, to high flow, okay, now we have to end the day. And so just that kind of stepwise progression is what's ultimately needed. So, got an interesting case, we go from just a little Narcan wake up to ICU for pulmonary edema for the treatment. So, there are no any questions or comments on that? I think multiple rounds of Narcan are more than... Yeah, you know, I don't think so, I think it's more just again, because it's like probably this breathing event that happens. So, it might be dose-related, I'm not quite sure, but I don't think it would be like multiple rounds as a thing. It's more just like, are they breathing against it and did that event cause it? So, a good question, any other questions or comments? Alright, right, let's have a good shift. Thank you so much. This has been the emergency medical minute. Thank you to our sponsor's care point, and HCA Health One.

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