SURGERY ON THE NARCOTIC ADDICT

Syndrome des « grosses mains » des toxicomanes : intérêt des bandages peu élastiques

BACKGROUND

Puffy hand syndrome is a complication of intravenous drug abuse, which has no current available treatment. Arm and forearm edema are voluminous and cause functional and aesthetic disturbances. We report two cases successfully treated by low-stretch bandages.

OBSERVATIONS

A 40-year-old man and a 34-year-old woman, both intravenous drug users, with puffy hand syndrome were hospitalized for 11 days. Treatment included daily multilayer bandaging. Lymphedema volumes calculated by utilizing the formula for a truncated cone decreased by 16% on the left side and 12% on the right side for the first patient and 31 and 17% for the second. Hand circumference decreased 4.3 cm on the left side and 3.2 cm on the right side in case 1, and 2.5 cm and 1.9 cm respectively for case 2. The patients were taught self-bandaging techniques during their hospital stays. Elastic gloves were fitted at the end of treatment. Reduction of lymphedema volume remained stable after 18 months in one patient while for the second patient further treatment and hospitalization were required due to poor compliance.

DISCUSSION

The pathogenesis of this edema is probably multifactorial: venous, lymphatic insufficiency and the direct toxicity of injected drugs. Lymphedema treatment currently consists of low-stretch bandaging and wearing elastic garments, which is effective in decreasing the volume of puffy hand syndrome.

Volumineux œdèmes des mains chez des patients toxicomanes intraveineux au long cours

Narcotic addiction may induce systemic and local complications. Intravenous injections of drugs can cause venous thrombosis, and septic or embolic complications. The puffy hand sign is a more uncommon complication of hard-core injection addicts. Three long-term intravenous drug users, two males, one female, mean age 30.6 years (26-37) presented puffy hands. These patients had been drug addicts for four to twelve years (mean duration 7.3 years) and had stopped heroin injections for 3-5 years (mean 4.6), participating in a buprenorphine substitution program. The edema appeared several years after drug cessation (1.5-5, mean 2.3). Typically the puffiness was bilateral, the hands swollen from the proximal segments of the fingers to the wrist. In one patient, the edema was localized both in the hands and in the feet. The edema was not pitting and unaffected by elevation. Duplex ultrasound examination of the extremities was normal. Lymphangiography performed in one patient was consistent with deep lymphatic destruction. Puffy hand syndrome appears to be the end result of lymphatic obstruction. Repeated injections of drugs in or outside the veins destroy the lymphatics. Buprenorphine may play an important role in the puffy hand sign. Although it is supposed to be administered orally, many drug addicts use it as an i.v. solution. Because buprenorphine is poorly soluble, it causes lymphatic obstruction. This type of hand for which no therapy exists must be differentiated from deep palmar space infection with dorsal edema which requires incision and drainage.

Substance abuse and withdrawal in the intensive care unit. Contemporary issues

Because 36% of intentional injury victims are drug dependent, the association between drug abuse and violence, especially in urban settings, is high. Withdrawal syndromes in ICU patients confuse their clinical management, may be extremely difficult to diagnose, are often lethal, need to be suspected, and should be prophylaxed against; therefore, all ICU patients should be considered to be at high risk for drug or alcohol dependence, should be tested for evidence of such drugs, and should be interviewed (together with their family members) for the presence of drug dependence traits. Appropriate patients should be referred for formal evaluation and treatment. Withdrawal syndromes must be promptly recognized, differentiated from traumatic or metabolic deterioration, and immediately treated. As patients are unique, so is their drug dependence. Individualized withdrawal therapy, not a "one method fits all" approach, works best. The mainstay of most withdrawal therapy is supportive care and benzodiazepine therapy. Also, considering the high rate of multiple intoxicants present in trauma patients, withdrawal can occur from multiple agents in a single patient, further compounding these difficulties. Withdrawal from unusual substances, such as GHB, or from therapeutic interventions (e.g., prolonged opioid or benzodiazepine administration) also must be considered.

David R. Boyd lecture in trauma care and emergency medical systems: "The surgical complications of toxins."

Toxins have had major roles in our societies for thousands of years. Interactions between surgeons, both generalists and subspecialists, and those caring for poisoned patients have been extensive throughout history. The advancement of the science of toxicology, the development of regional poison control centers, the development of emergency medicine, and the development of the subspecialty of medical toxicology have led to more appropriate and creative interactions between medical toxicologists, emergency physicians, and surgeons. This article will review the diverse interfaces between the medical toxicologist and the surgeon.

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