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Case

The Case of the Comatose Prisoner James Roberts, MD The Medical College of Pennsylvania/ Hahnemann University Drexel University School of Medicine Mercy Catholic Medical Center Philadelphia, Pennsylvania. Case.

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Case

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  1. The Case of the Comatose PrisonerJames Roberts, MDThe Medical College of Pennsylvania/ Hahnemann UniversityDrexel University School of MedicineMercy Catholic Medical CenterPhiladelphia, Pennsylvania

  2. Case A 28 y/o suspected cocaine dealer was involved in a police chase that ended with the suspect’s car ramming a pole. The extrication took 30 minutes due to significant vehicle damage. The man was awake at the scene and was taken to a hospital for evaluation.

  3. Case At the hospital he had a pulse of 110/min but otherwise normal vital signs and no complaints. Other than a facial abrasion and a small scalp hematoma, the physical examination was normal. In the ED he was agitated and urinated on the floor of the examining room (“I couldn’t hold it”).

  4. Case No laboratory tests or X rays were performed. He was observed for 2 hours, “remained stable,” and was discharged into police custody at 9pm with a diagnosis of “minor soft tissue injuries.” At the jail he was placed in a cell with 3 other prisoners. At 8am he was unarousable and was returned to the hospital.

  5. Case • Upon arrival: • Temp: 97.4 R • BP: 124/60 • Pulse: 78/min • Resp: 16/min • POx 99% on RA • Monitor: sinus rhythm • He was incontinent of urine • Differential diagnosis at this juncture?

  6. Differential Diagnosis • Head trauma • CVA • Hypoglycemia/Hyperglycemia • Drug Overdose (body packer, additional ingestion in jail) • Post Ictal • Malingering • Wernicke’s encephalopathy • Sepsis, CNS infection, hepatic coma, hypernatremia

  7. Further History: • No old records available • No answer at home phone • Police clueless • Previous ED visit confirmed • Next step: further evaluation/treatment

  8. Further Examination • Facial injury/scalp hematoma • No Battle’s sign/ no hemotympanum • Abdomen/chest/extremities demonstrated no abnormality • No other signs of trauma • No sign of IVDA • Body habitus of chronic cocaine use • What are the key components of the neurologic examination?

  9. Neurologic Examination • No response to deep pain/no posturing • Pupils: 2-3 mm and sluggish • Dysconjugate gaze present • No gag reflex • Flaccid extremities/no reflexes elicited • Negative Babinski sign, no clonus, no fasciculations • Outline the Basic Initial Treatment

  10. Initial Basic Treatment • Safety net: IV, Oxygen, monitor, pulse ox, dynamap • Dextrostick: glucose 110 • Foley catheter: clear urine • ABG: pH 7.43; PO2: 145 torr on 2 liters; PCO2 42 torr; HCO3: 23 • Intubated for airway protection • Note: no response to above procedures, including intubation • What definitive tests are required at this juncture?

  11. Results of Tests: • Head CT scan: negative • CBC, Electrolytes, BUN/CR, PT/PTT : Normal Urine drug screen: (+) cocaine, (-) for barbs, benzo, opiates • Serum ethanol : 10 mg% • Lumbar puncture: normal opening pressure, neg chemistry/no cells • EKG: Normal • Liver function/ammonia: normal • What therapies are reasonable?

  12. Therapy: Probably Warranted • Small dose naloxone, charcoal, thiamine • Toxicology/poison center consultation • Neurology consultation • ICU admission

  13. Therapy: Probably Not Warranted • Flumazenil • Gastric lavage/WBI • Antibiotics • MRI

  14. Hospital Course • Admitted to the ICU. Over the next 12-16 hours the patient slowly woke up, was extubated, and admitted to a 2-week crack cocaine binge, but denied other drugs. He related numerous such “crashes” when he ran out of money for cocaine. • DIAGNOSIS: The cocaine washout syndrome

  15. Pathophysiology of the Cocaine Washout Syndrome • Most likely a lack of CNSneurotransmitters • Norepinephrine • Serotonin • Dopamine

  16. Incidence/Clinical Caveats • Incidence unknown, likely quite common • No data in the medical literature, but street knowledge • Occurs when drug use halted (medical illness, jail, insolvent) • Precipitated in ED with minimal benzodiazepine administration • Vital signs normal, usually not hypotensive, bradycardic • Signs of cocaine toxicity absent • Patients appear in a deep sleep state • Nonresponsiveness may be quite impressive

  17. Clinical Approach • Diagnosis • Clinical diagnosis/rule out other conditions • No known value of catecholamine level • Urine positive for cocaine • May require extensive, expensive R/O workup • Treatment • Supportive only/protect airway and vital signs • Stimulants not warranted • Course • Patients wake up slowly over 12-24 hours

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