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OPIUM POISONING: A CASE FOR ENERGETIC TREATMENT
Brit, J. Anaesth. (1968), 40, 387
OPIUM POISONING: A CASE FOR ENERGETIC TREATMENT BY
R. N. T. THIN, R. E. NEEDS, R. N. EVANS AND A. T. COOK SUMMARY
Acute poisoning due to opium or its derivatives is rare. Graham (1962) noted that narcotics formed 0.92 to 2.6 per cent of the admissions to hospital for acute poisoning. Matthew and associates (1966) recorded the cases of one patient who had taken pethidine and of three who had taken mixtures containing codeine, in a series of 259 acute poisonings. Acute narcotic poisoning appears to be rare in the general population of Singapore; for instance in 1961 one case of narcotic overdose was recorded in 769 poisonings (Report of the Ministry of Health for the State of Singapore). The last case of narcotic poisoning admitted to this hospital was in 1964 when a patient was admitted suffering from an overdose of pethidine. A case of acute opium poisoning of a soldier stationed in Singapore is presented. The management and implications are discussed. CASE REPORT A 22-year-old white male who had swallowed 750 mg of prepared opium 12 hours previously was admitted to hospital as an emergency. He was deeply unconscious, cyanosed, the pupils were markedly constricted and the left lung was collapsed. His blood pressure was 90/64 mm Hg. A portable chest radiograph confirmed collapse of the left lung (fig. 1). Emergency treatment was started by clearing the airway, administering oxygen, 1,000,000 units of benzylpsnicillin, and intravenous injections of hydrocortisone hemisuccinate 100 mg, and nalorphine hydrobromide 10 mg. An endotracheal tube was inserted and he was at once transferred to the theatre for bronchoscopy. While being moved he was ventilated manually. At bronchoscopy vomitus was aspirated from the left bronchial tree. The bronchi were washed out with saline until no more vomitus could be obtained; 350 ml of saline were required. Four ml of 2 per cent lignocaine hydrochloride was then instilled, the bronchoscope was withdrawn and an endotracheal tube inserted. By this time the blood pressure had risen to 110/75 mm Hg, he was no longer cyanosed and was breathing spontaneously with a minute volume of 5 L/min. Figure 2 shows the radiographic appearance immediately after bronchoscopy. He recovered consciousness 2 hours later, having had another 10 mg of
nalorphine hydrobromide intravenously during the interval. Treatment was continued with systemic corticosteroids, penicillin, and vigorous physiotherapy. A chest radiograph taken 9 days after admission was normal and he returned to work the following day.
FIG. 1 On admission.
DISCUSSION
Management. The effects of the inhalation of gastric contents are well known (Mendelson, 1946; Mucklow and Larard, 1963). Our treatment followed the accepted methods (McCormick, 1966) with the addition of lignocaine instillation into the affected
Downloaded from http://bja.oxfordjournals.org/ at University of Western Ontario on April 11, 2015
A case is presented of a 22-year-old white male who was admitted to hospital after an overdose of opium complicated by inhalation of gastric contents. Emergency treatment, including bronchoscopy and lavage, were successful both in saving his life and in enabling the radiographic appearance of the chest to return to normal within 9 days.
381
BRITISH JOURNAL OF ANAESTHESIA At present Europeans usually try opium out of curiosity and poisoning is rare. However, the increased prevalence of drug-taking by young people in Great Britain (Brit. med. J., 1967) suggests that cases of opium poisoning may be more common in the future. ACKNOWLEDGEMENT
REFERENCES
FIG. 2 After bronchoscopy.
bronchi. Wylie and Churchill-Davidson (1966) note that topical lignocaine reduces the incidence of laryngeal spasm at bronchoscopy; one of us (R.E.N.) suggested that it would have a similar effect on the bronchi, reducing any persisting bronchospasm of the asthma-like phase of Mendelson's syndrome. This would increase oxygen uptake during the period after bronchoscopy before other measures were fully effective.
Opium. Most of the opium smuggled into Sinppore is grown in the frontier regions of Burma, Thailand, Laos and the Yunnan Province of China; it is prepared by boiling and sold in 750-mg packets containing 33 to 50 mg of morphine. This is normally smoked by addicts over the course of 20 minutes: our patient swallowed a packet in 2 minutes and lost consciousness half an hour later. Although serious symptoms are uncommon with doses below 60 mg (Reynolds and Randall, 1957) this man's intake was sufficient to precipitate a dangerous condition.
Bn'r. med. J. (1967), 2, 67. (Drug-taking by the young.) Graham, J. D. P. (1962). The Diagnosis and Treatment of Acute Poisoning, p. 18. London: Oxford University Press. Matthew, H., Mackintosh, T. F., Tompsett; S. L., and Cameron, J. C. (1966). Gastric aspiration and lavage in acute poisoning. Brit. med. J., 1, 1333. McCormick, P. W. (1966). The severe pulmonary aspiration syndrome in obstetrics. Proc. roy. Soc. Med., 59, 66. Mendelson, C. L. (1946). Aspiration of stomach contents into the lungs during obstetric anesthesia. Amer. J. Obstet. Gynec, 52, 191. Mucklow, R. G., and Larard, D. G. (1963). The effects of the inhalation of vomitus on the lungs: clinical considerations. Brit. J. Anaesth., 35, 153. Report of Ministry of Health of the Stale of Singapore for 1961, p. 81. Reynolds, A. K., and Randall, L. O. (1957). Morphine and Allied Drugs, p. 119. University of Toronto Press. Wylie, W. D., and Churchill-Davidson, H. C (1966). A Practice of Anaesthesia, 2nd ed., p. 324. London: Lloyd-Luke Medical Books. EMPOISONNEMENT PAR L'OPIUM: UN CAS RELEVANT DOJN TRAITEMENT ENERGIQUE SOMMAIRE
On presente un cas d'un blanc de sexe masculin &g& de 22 ans, admis a l'hdpital apres une dose trop forte d'opium compliqu6 par inhalation du contenu gastrique. Traitement d urgence comprenant bronchoscopie et lavage furent tus deux couronnes de succes en lui sauvant la vie, et en permettant de prendre un cliche radiographique des voies respiratoires, de revenir a la normale au bout de 9 jours. OPIUMVERGIFTUNG: EIN FALL FOR EINE ENERGISCHE BEHANDLUNG ZUSAMMENFASSUNG
Der Fall eines 22-jahrigen weiOen Mannes wird dargestellt, der nach einer Uberdosis Opium in die Klinik eingewiesen wurde. Als Komplikation kam hinzu, dafi der Patient Mageninhalt eingeatmet hatte. Die Notfallbehandlung, die Bronchoskopie und Spulung einschloB, war erfolgreich. Sie rettete sein Leben und ermSglichte es, dafi das Rontgenbild der Brust sich innerhalb von neun Tagen normalisierte.
Downloaded from http://bja.oxfordjournals.org/ at University of Western Ontario on April 11, 2015
The authors gratefully acknowledge the help received from the Special Investigation Branch and the Narcotics Division of the Criminal Investigation Department of Singapore.
OPIUM POISONING: A CASE FOR ENERGETIC TREATMENT BY
R. N. T. THIN, R. E. NEEDS, R. N. EVANS AND A. T. COOK SUMMARY
Acute poisoning due to opium or its derivatives is rare. Graham (1962) noted that narcotics formed 0.92 to 2.6 per cent of the admissions to hospital for acute poisoning. Matthew and associates (1966) recorded the cases of one patient who had taken pethidine and of three who had taken mixtures containing codeine, in a series of 259 acute poisonings. Acute narcotic poisoning appears to be rare in the general population of Singapore; for instance in 1961 one case of narcotic overdose was recorded in 769 poisonings (Report of the Ministry of Health for the State of Singapore). The last case of narcotic poisoning admitted to this hospital was in 1964 when a patient was admitted suffering from an overdose of pethidine. A case of acute opium poisoning of a soldier stationed in Singapore is presented. The management and implications are discussed. CASE REPORT A 22-year-old white male who had swallowed 750 mg of prepared opium 12 hours previously was admitted to hospital as an emergency. He was deeply unconscious, cyanosed, the pupils were markedly constricted and the left lung was collapsed. His blood pressure was 90/64 mm Hg. A portable chest radiograph confirmed collapse of the left lung (fig. 1). Emergency treatment was started by clearing the airway, administering oxygen, 1,000,000 units of benzylpsnicillin, and intravenous injections of hydrocortisone hemisuccinate 100 mg, and nalorphine hydrobromide 10 mg. An endotracheal tube was inserted and he was at once transferred to the theatre for bronchoscopy. While being moved he was ventilated manually. At bronchoscopy vomitus was aspirated from the left bronchial tree. The bronchi were washed out with saline until no more vomitus could be obtained; 350 ml of saline were required. Four ml of 2 per cent lignocaine hydrochloride was then instilled, the bronchoscope was withdrawn and an endotracheal tube inserted. By this time the blood pressure had risen to 110/75 mm Hg, he was no longer cyanosed and was breathing spontaneously with a minute volume of 5 L/min. Figure 2 shows the radiographic appearance immediately after bronchoscopy. He recovered consciousness 2 hours later, having had another 10 mg of
nalorphine hydrobromide intravenously during the interval. Treatment was continued with systemic corticosteroids, penicillin, and vigorous physiotherapy. A chest radiograph taken 9 days after admission was normal and he returned to work the following day.
FIG. 1 On admission.
DISCUSSION
Management. The effects of the inhalation of gastric contents are well known (Mendelson, 1946; Mucklow and Larard, 1963). Our treatment followed the accepted methods (McCormick, 1966) with the addition of lignocaine instillation into the affected
Downloaded from http://bja.oxfordjournals.org/ at University of Western Ontario on April 11, 2015
A case is presented of a 22-year-old white male who was admitted to hospital after an overdose of opium complicated by inhalation of gastric contents. Emergency treatment, including bronchoscopy and lavage, were successful both in saving his life and in enabling the radiographic appearance of the chest to return to normal within 9 days.
381
BRITISH JOURNAL OF ANAESTHESIA At present Europeans usually try opium out of curiosity and poisoning is rare. However, the increased prevalence of drug-taking by young people in Great Britain (Brit. med. J., 1967) suggests that cases of opium poisoning may be more common in the future. ACKNOWLEDGEMENT
REFERENCES
FIG. 2 After bronchoscopy.
bronchi. Wylie and Churchill-Davidson (1966) note that topical lignocaine reduces the incidence of laryngeal spasm at bronchoscopy; one of us (R.E.N.) suggested that it would have a similar effect on the bronchi, reducing any persisting bronchospasm of the asthma-like phase of Mendelson's syndrome. This would increase oxygen uptake during the period after bronchoscopy before other measures were fully effective.
Opium. Most of the opium smuggled into Sinppore is grown in the frontier regions of Burma, Thailand, Laos and the Yunnan Province of China; it is prepared by boiling and sold in 750-mg packets containing 33 to 50 mg of morphine. This is normally smoked by addicts over the course of 20 minutes: our patient swallowed a packet in 2 minutes and lost consciousness half an hour later. Although serious symptoms are uncommon with doses below 60 mg (Reynolds and Randall, 1957) this man's intake was sufficient to precipitate a dangerous condition.
Bn'r. med. J. (1967), 2, 67. (Drug-taking by the young.) Graham, J. D. P. (1962). The Diagnosis and Treatment of Acute Poisoning, p. 18. London: Oxford University Press. Matthew, H., Mackintosh, T. F., Tompsett; S. L., and Cameron, J. C. (1966). Gastric aspiration and lavage in acute poisoning. Brit. med. J., 1, 1333. McCormick, P. W. (1966). The severe pulmonary aspiration syndrome in obstetrics. Proc. roy. Soc. Med., 59, 66. Mendelson, C. L. (1946). Aspiration of stomach contents into the lungs during obstetric anesthesia. Amer. J. Obstet. Gynec, 52, 191. Mucklow, R. G., and Larard, D. G. (1963). The effects of the inhalation of vomitus on the lungs: clinical considerations. Brit. J. Anaesth., 35, 153. Report of Ministry of Health of the Stale of Singapore for 1961, p. 81. Reynolds, A. K., and Randall, L. O. (1957). Morphine and Allied Drugs, p. 119. University of Toronto Press. Wylie, W. D., and Churchill-Davidson, H. C (1966). A Practice of Anaesthesia, 2nd ed., p. 324. London: Lloyd-Luke Medical Books. EMPOISONNEMENT PAR L'OPIUM: UN CAS RELEVANT DOJN TRAITEMENT ENERGIQUE SOMMAIRE
On presente un cas d'un blanc de sexe masculin &g& de 22 ans, admis a l'hdpital apres une dose trop forte d'opium compliqu6 par inhalation du contenu gastrique. Traitement d urgence comprenant bronchoscopie et lavage furent tus deux couronnes de succes en lui sauvant la vie, et en permettant de prendre un cliche radiographique des voies respiratoires, de revenir a la normale au bout de 9 jours. OPIUMVERGIFTUNG: EIN FALL FOR EINE ENERGISCHE BEHANDLUNG ZUSAMMENFASSUNG
Der Fall eines 22-jahrigen weiOen Mannes wird dargestellt, der nach einer Uberdosis Opium in die Klinik eingewiesen wurde. Als Komplikation kam hinzu, dafi der Patient Mageninhalt eingeatmet hatte. Die Notfallbehandlung, die Bronchoskopie und Spulung einschloB, war erfolgreich. Sie rettete sein Leben und ermSglichte es, dafi das Rontgenbild der Brust sich innerhalb von neun Tagen normalisierte.
Downloaded from http://bja.oxfordjournals.org/ at University of Western Ontario on April 11, 2015
The authors gratefully acknowledge the help received from the Special Investigation Branch and the Narcotics Division of the Criminal Investigation Department of Singapore.