Article

Brain computed tomographic scan findings in acute opium overdose patients

Unlabelled imageAmerican Journal of Emergency Medicine (2013) 31, 50-53

Original Contribution

Brain computed tomographic scan findings in acute opium overdose patients?

Farkhondeh Jamshidi MD a, Babak Sadighi MD a, Kamran Aghakhani MD a,

Hossein Sanaei-Zadeh MD a,?, Mohammadali Emamhadi MD b, Nasim Zamani MD a

aDepartment of Forensic Medicine and Toxicology, Tehran University of Medical Sciences, Hazrat Rasoul Akram Hospital,

Tehran, Iran

bDepartment of Forensic Medicine and Toxicology, Loghman Hakim Poison Hospital, Shaheed-Beheshti University of Medical Sciences, Tehran, Iran

Received 30 April 2012; revised 24 May 2012; accepted 25 May 2012

Abstract

Aim: Early Radiologic evaluations including noncontrast computed tomographic (CT) scan of the brain have been reported to be useful in the diagnosis and management of the Intoxicated patients. Changes in the brain CT scan of the acute opium overdose patients have little been studied to date. This study aimed to evaluate changes of the brain CT scans in the acute opium overdose patients.

Methods: In this retrospective study, medical records of all acute opium overdose patients hos- pitalized in Loghman-Hakim Poison Hospital in Tehran, Iran, between September 2009 and September 2010 were identified. Those who had undergone noncontrast brain CT within the first 24 hours of hospital presentation were included. Patients with any underlying disease, head trauma, underlying central nervous system disease, epilepsy, and multidrug ingestion were excluded. The patients’ demographic information, vital signs, and laboratory data at presentation were extracted and recorded. The data were analyzed using SPSS software version 17 (SPSS, Chicago, IL).

Results: A total of 71 patients were included. Fifty-eight patients (80.5%) survived, and 10 (13.8%) died. Fourteen cases (19.7%) had abnormal CT findings including 8 cases of generalized cerebral edema and 6 cases of infarction/ischemia. There were no statistically significant differences between the patients with and without abnormal CT scan findings with respect to age, sex, systolic and/or diastolic blood pressures, pulse rate, respiratory rate, occurrence of seizures, pH, PCO2, HCO, blood sodium level, and blood glucose level (all P values were N .05). However, a statistically significant difference was found between these patients in terms of outcome (P = .007).

3

Conclusion: Abnormal brain CT findings are detected in about 20% of the acute opium overdose patients who are ill enough to warrant performance of the brain CT scan and associate with a poor prognosis in this group of the patients.

(C) 2013

? Conftict of interest: The authors report no confticts of interest. The authors alone are responsible for the content and writing of this article.

* Corresponding author.

E-mail address: [email protected] (H. Sanaei-Zadeh).

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2012.05.030

Brain CT scan findings in acute opium overdose patients

Introduction

The value of early radiologic evaluations in the intoxicated patients has already been shown. In such patients, noncontrast computed tomographic (CT) scan of the brain has a known role in the diagnosis of the intracranial pathologies [1,2]. Structural changes may be due to acute or chronic and reversible or irreversible intoxications. In addition, their pattern of involvement may be specific or nonspecific [1]. The primary involvement of the brain due to the medications and toxins may be directly or indirectly induced [1]. Acute overdose of some of the opioids has direct toxic effects on the brain [1,3]. Those indirectly affecting the brain induce hypoxia or hypo/hypertension [1]. Secondary complications on the brain due to the added impurities or associatED diseases (infections or seizures) may also happen [1].

The drug most abused in the opioid group is heroin [1]. Other derivatives include morphine, codeine, hydrocodone, oxycodone, hydromorphine, phentanyl, meperidine, metha- done, and opium [1]. The changes in the brain CT scan of the acute opium overdose patients have less been studied [4]. Opium, a mixture of morphine, codeine, tebaine, papaverine, noscapine, and other alkaloids is one of the most commonly abused substances in our country [5,6]. This study aimed to evaluate changes of the brain CT scans in the acute opium overdose patients.

Materials and methods

In this retrospective study, medical records of all acute opium overdose patients who had been hospitalized in Loghman-Hakim Poison Hospital in Tehran, Iran, between September 2009 and September 2010 were identified by the computerized discharge diagnosis (International Statistical Classification of Diseases, 10th Revision) codes. Our in- clusion criteria were (1) isolated overdose with opium and

(2) performance of noncontrast brain CT within the first

24 hours of hospital presentation. These cases were the Unconscious patients (with both of the aforementioned inclusion criteria) who had partially responded to the ad- ministration of naloxone in spite of the clear history of isolated opium use and did not need to be intubated, had been intubated without the Naloxone administration at pre- sentation, or naloxone had been administered to them with- out obtaining dramatic response and had been intubated. The diagnosis of acute opium poisoning had been made based on the positive history of ingestion or inhalation given by the relatives or the patient himself/herself after regaining con- sciousness with the conservative treatment. Treatment for these patients included administration of naloxone and gut decontamination, oxygen therapy, and intubation and mech- anical ventilation if necessary.

The exclusion criteria were (1) having any underlying diseases (renal, liver, cardiac, pulmonary, and endocrine diseases resulting in encepahalopathy), (2) head trauma, (3)

51

underlying central nervous system diseases, (4) epilepsy, and

(5) multidrug ingestion (based on the patients’ history). The patients’ demographic information, vital signs and clinical manifestations, and laboratory data at presentation including systolic and diastolic blood pressures, pulse rate, respiratory rate, temperature, arterial blood gas analyses, blood sodium and glucose levels, CT findings, and the patients’ outcome were extracted from the medical records and entered into the standardized data abstraction forms. noncontrast CT scans had been performed by a single scanner (Shimadzu, 7800; Japan) using the sequential techniques (collimation, 10 mm; spacing, 10 mm). For the performance of the brain CT scans, the patients’ heads had been placed in the head holder, and none of the patients had been sedated or paralyzed. The CTs had been interpreted and reported by the hospital attendant radiologists. An interrater reliability analysis (K statistic) [7] was done to determine the consistency of the evaluation of the CTs (ie, detection of an abnormal CT finding and its type). The data were double extracted, and any discrepancy was resolved by reviewing the original CTs. Statistical analysis was performed using SPSS (Statistical Package for Social Sciences) software (version 17; Chicago, IL) and application of descriptive statistics, Kolmogorov-Smirnov, Mann-Whitney U test, Student t test, and Pearson ?2 test. P b .05 was considered to be statistically significant. Our study was approved by the regional ethics committee.

Results

A total of 71 patients met our inclusion criteria and were included. Mean age of the patients was 50 +- 19.7 years (range, 5-86 years). Sixty-four (90.1%) were male, and 7 (9.9%) were female. A total of 58 patients (80.5%) survived, and 10 (13.8%) died. Three patients had been referred to other clinics, and no information about their outcome was available in their medical records. These 3 patients were, therefore, excluded from the statistical analysis. Thirty-three patients (46.5%) had been intubated at presentation. The patients’ demographic characteristics, vital signs and clinical manifestations, laboratory data at presentation, and outcome are shown in Table 1. Fourteen cases (19.7%) had short-term structural changes observed in their CT scans [1,4] including 8 cases of generalized cerebral edema and 6 cases of infarc- tion/ischemia. The K for the interrater reliability analysis for CT interpretation between the radiologists was 0.84 (95% confidence interval, 0.67-1.00) with P b .001. There were no statistically significant differences between the patients with and without abNormal CT scan findings with respect to age, sex, systolic and/or diastolic blood pressures, pulse rate, respiratory rate, occurrence of seizures, pH, PCO2, HCO, blood sodium level, and blood glucose level (all P values were N .05). However, a statistically significant difference was found between these patients in terms of outcome (P =

3

.007, Table 1). Such statistically significant difference was

52 F. Jamshidi et al.

Table 1 Demographic characteristics, vital signs and clinical manifestations at presentation, arterial blood gas analyses, blood sodium level, blood glucose level, and outcome in all patients and patients with and without abnormal CT scan findings

All

Patients with abnormal CT findings

Patients with normal CT findings

P value (applied statistical test)

No. of patients Age (y)

Sex (male/female)

Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Pulse rate (beats/min)

Respiratory rate (per min)

Frequency of seizures pH

PCO2 (mm Hg) HCO (mmol/L)

3

Blood sodium level (mEq/L) Blood glucose level (mg/dL)

Outcome (survived/nonsurvived/undetermined)

71

50 +- 19.7

64/7

123.5 (+- 23.6)

77.9 (+- 13.8)

88 (+- 19)

16 (+- 10)

10

7.32 (+- 0.16)

50.73 (+- 19.21)

25.73 (+- 6.54)

143 (+- 5.5)

119 (+- 38)

58/10/3

14

48 +- 23.6

14/0

121.9 (+- 23)

75.7 (+- 9.4)

95 (+- 32)

21 (+- 15)

3

7.39 (+- 0.14)

43.22 (+- 15.12)

25.94 (+- 6.18)

146 (+- 7.6)

129 (+- 41)

8/5/1

57

50.6 +- 18.8

50/7

123.9 (+- 23.9)

78.5 (+- 14.8)

86 (+- 15)

15 (+- 8)

7

7.30 (+- 0.16)

52.52 (+- 19.77)

25.68 (+- 6.69)

142 (+- 4.8)

113 (+- 36)

50/5/2

.772 (MWU)

.331 (Fisher exact test)

.725 (MWU)

.822 (MWU)

.545 (MWU)

.216 (MWU)

.402 (Fisher exact test)

.070 (MWU)

.075 (MWU)

.599 (MWU)

.143 (MWU)

.359 (MWU)

.007 (Pearson ?2)

Data are presented as mean value (+-SD). All P values were insignificant except for the P given for the outcome. MWU, Mann-Whitney U test.

also noted between the survivors and nonsurvivors regarding the frequency of intubation (P = .001).

Discussion

This study shows that generalized cerebral edema is the most commonly encountered acute neurovascular complica- tion caused by opium that is maybe due to Cerebral hypoxia. During hypoxia, incomplete combustion of glucose happens which leads to the formation of lactate and hydrogen ion contributing to the development of cerebral edema (initially, cytotoxic, and, subsequently, interstitial) [8].

Furthermore, direct effects of the opium alkaloid constituents with reversible vasospasm from stimulation of the vascular smooth muscles by the u Opioid receptors may result in local ischemia/infarction seen in this study [1].

Only 1 previous study has shown abnormal brain CT scans in 15.2% of the 92 acute opium overdose patients. These abnormal findings included infarction and/or hem- orrhage in 10.8%, cerebral edema in 3.3%, and hypodensity of the basal ganglia in 1.1% of their patients [4]. In con- trast, we found no basal ganglia changes and hemorrhage in our patients.

The present study shows that the presence of ischemia and infarction in acute opium overdose patients is accompanied by a poor prognosis (Table 1). In addition, intubation after hospital presentation can determine the patients’ outcome as well as the abnormal brain CTs. It should be mentioned that we found abnormal brain CT in about 20% of our acute opium overdose patients who were ill enough to undergo a brain CT. Certainly, the frequency of abnormal CTs would have been much lower if we had included all the acute opium overdose patients including those who were not ill enough to undergo a CT.

Except for the abnormal CT findings, our results show that an acute opium overdose patient can present without respiratory depression. As shown in the present study, mean respiratory rate (at hospital presentation and before the performance of intubation for the patients) was 16 (+- 10) in these patients, which may be due to the opium ingredients, aspiration pneumonitis, or pulmonary edema [9]. To the best of our knowledge, this remarkable point has not been men- tioned in the available literature.

Furthermore, about 1.5% of the acute opium overdose patients have presented with seizure. However, it has been shown that seizures and focal neurologic signs are usually absent after opiate intoxication, except for morphine, in which they have been reported to occur in neonates [10,11]. To date, only 1 case report describes severe convulsions after opium overdose in an adult [12]. Of note, our study shows that there is no association between the abnormal CT scan findings and occurrence of seizure.

The most important limitation of the current study is the diagnosis of isolated opium overdose and exclusion of multidrug ingestions that had been made based on the positive history of ingestion or inhalation given by the rela- tives or the patient without confirmatory laboratory tests being available. Another limitation of our study was that accurate measurement of the consumed opium was not possible, and therefore, we could not comment on its corre- lation with abnormal CT findings. In addition, because of the few number of our cases, further prospective investigations with larger sample sizes are warranted.

Conclusion

Abnormal brain CT findings are detected in about 20% of the acute opium overdose patients who are ill enough to

Brain CT scan findings in acute opium overdose patients 53

warrant performance of the brain CT scan. These abnormal findings are associated with a poor prognosis in this group of the patients.

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