TOXIC INHALATIONAL LUNG INJURY FROM COUNTERFEIT ALPRAZOLAM REFRACTORY TO MECHANICAL VENTILATION REQUIRING VENO-VENO ECMO

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: As substance abuse continues plague our country, drug dealers are finding creative ways to make product the looks deceptively like the manufacturer’s product. The pills are created by combining the active substance with various dry chemical compounds to mimic the authentic medication. When ingested, these compounds may be benign, but inhaled can cause diffuse airway injury leading to respiratory failure. CASE PRESENTATION: The patient was a 33 year old male who presented to the Emergency Department by EMS after being discovered unresponsive at home. Per witness report, the patient had been disoriented most of the day and well known to abuse alprazolam and opiates by crushing the pills and inhaling the medication. He was intubated in the field and brought to the ED before being admitted to the ICU with the presumptive diagnosis of drug overdose. Several hours later the patient began having difficulty with high peak and plateau pressures as well as respiratory acidosis. He was noted to be in bronchospasm and was immediately started on bronchodilators and steroids. The hypercapnea persisted despite paralyzing the patient, aggressive medical therapy and multiple ventilatory strategies. He ultimately required V-V ECMO to correct the respiratory defect. He remained on ECMO for a total of 3 days and was successfully extubated 7 days after presentation. During the admission he developed progressive diffuse bilateral reticulonodular opacities on chest radiograph. The patient was eventually weaned to room air and left the hospital AMA after 10 days in the hospital. He returned to the hospital 5 days later with a “tree-in-bud" pattern on Chest CT, suggesting bronchiolitis. In talking with the patient, he adamantly denied injection drug use and admitted that his supplier made the pills with a kit he purchased from the internet. DISCUSSION: Counterfeit medications for the purposes of abuse are becoming an increasing problem in the United States. There have been multiple case reports documenting clusters of overdoses and deaths related to these counterfeit medications. The events are often associated with large concentrations of synthetic opiates or additional psychoactive medications that were not advertised. Kits to create these medications as well as medications not normally abused are available for purchase on the internet. The compounds used to make these counterfeit medications are not regulated by any regulatory body and the exact composition is not typically known. Airway injury secondary to toxic inhalation can occur with the inhalation of a variety of organic and inorganic compounds and can manifest as bronchitis, bronchospasm, bronchiolitis, epithelial desquamation or ARDS. CONCLUSIONS: While drug overdose is a common cause of respiratory failure in the intensive care unit, clinicians must remain vigilant for other acute complications of substance abuse including direct injury to the airway. Reference #1: Mason RC, Murray JF, Nadel JA, et al. Murray & Nadel's Textbook of Respiratory Medicine E-Book. Elsevier Health Sciences; 2015. DISCLOSURES: No relevant relationships by Ryan Griffith, source=Web Response No relevant relationships by Mohammad Taleb, source=Web Response