1 / 21

COCAINE 101 for the (E)Medical Student

Brigham Dastrup, BA March 7, 2006. COCAINE 101 for the (E)Medical Student . Case Presentation.

latoya
Download Presentation

COCAINE 101 for the (E)Medical Student

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Brigham Dastrup, BA March 7, 2006 COCAINE 101for the (E)Medical Student

  2. Case Presentation • 44yo female with h/o HTN presents with 24 hour acute exacerbation of chronic substernal chest pain. Chest pain not exertional. She describes radiation to her left arm. (+) dyspnea (baseline) (-)Nausea/vomiting, (-) diaphoresis • “Very high” blood pressure at outside medical center • “3 valves are blocked” possible CAD • EKG—no changes from previous study • Cardiac enzymes—negative x3 • Chest X-ray unremarkable

  3. Differential Diagnosis • MI • PE • Pneumothorax • Pneumonia • Anxiety • Endocarditis • Aortic Dissection Wait a minute, I forgot to tell you something. . . .

  4. The Rest of the Story Which of the following do you use? Tobacco Yes No Alcohol Yes No Drugs Yes No

  5. The Rest of the Story Which of the following do you use? Tobacco Yes No Alcohol Yes No Drugs Yes No Cocaine use yesterday, EtOH every day

  6. Back to the Differential • NSTEMI • PE • Pneumothorax • Pneumonia • Anxiety • Endocarditis • Aortic Dissection • Cocaine Chest Pain??? First some background. . .

  7. Brief History of Cocaine • Ancient Incas believed cocaine to be a gift from the gods • 1884—William Halsted performed the first nerve block using cocaine as the anesthetic, eventually became dependent • Same year—Sigmund Freud publishes article on cocaine, advocates its use in the treatment of asthma, wasting diseases and syphilis, also became dependent

  8. Brief History of Cocaine • 1885—John Smyth Pemberton registers “French Wine Cola” in the US. Popular product contains 60mg of cocaine • Later renamed Coca-cola. Contained cocaine until 1903. Coca-cola today still contains an extract of coca leaves

  9. Cocaine Terminology for Dummies • Body packer—carefully wraps packages and uses GI tract as hiding place for drug transport • Body stuffer—similar to packer but done more quickly (less safely) when faced with police, etc. • Crack—Cocaine HCl concentrated by heating the drug in baking soda until water evaporates; name comes from “cracking” sound made when heated

  10. Cocaine Terminology for Dummies • Cut drugs—drugs mixed with other similar appearing substances (clinical significance) • Slammed cocaine—cocaine used IV • SPEEDBALL—heroin injected or snorted followed immediately by smoking of cocaine

  11. Back to Cocaine in the ER • Powerful stimulant of the sympathetic NS • Signs of Cocaine Use • Tachycardia • Dilated Pupils • Hypertension • Hyperthermia • Profuse Diaphoresis • Agitation

  12. ER Presentation of Cocaine Use • Cardiac • Chest pain -MI • Arrythmias -Cardiomyopathy • Vascular (spasms) • Blindness -Renal Infarction • Limb Ischemia -Intestinal Ischemia • Aortic Dissection • Respiratory • Pneumothorax • Pulmonary hemorrhage/infarction • Diffuse Alveolar Hemorrhage • Pulmonary Edema • Asthma Exacerbation • Eosinophilic Lung Disease etc. etc. • Neurologic • CVA -Seizures • “crack dancing” extrapyramidal sxs • Metabolic • Hyperglycemia - Acidosis • Hyperkalemia • Ophthalmologic • Cerebral vasculitisdecreased visual acuity or blindness • Numerous other problems • Excited/Agitated Delirium • Hyperthermia (45.6C—114F!!) • Etc.etc.etc.

  13. A few specifics. . . • Chest Pain—Most common ER complaint associated with cocaine use • Dr. Richard Lange study: “Of patients who come to the emergency department with nontraumatic chest pain, 14-25% in urban hospitals. . .have detectable levels of cocaine or cocaine metabolites in their blood” • Above study cautions that cocaine must be seriously considered in differential for chest pain especially in patients with few other risk factors for atherosclerosis

  14. Cocaine Chest Pain Challenges • EKG • High failure rate in detecting MI (Sens—36%) • 43% of cocaine abusers without myocardial infarction meet EKG criterion for initiation of reperfusion therapy (ST elev. in 2 contiguous leads) • Creatine kinase • Elevated in half of cocaine users who do not have MI • Troponin more reliable

  15. Cocaine Chest Pain Treatment • Nitroglycerin/Verapamil—reverse cocaine-induced HTN and vasoconstriction of coronary arteries • Aspirin—Inhibit Platelet aggregation • Benzos—reduced heart rate, blood pressure, may attenuate cocaine’s toxic effects on heart and nervous system • Phentolamine—reverses vasoconstriction of coronaries

  16. Cocaine Chest Pain Treatment • Beta-blockers, best not to use • Selective beta block leaves alpha1 tone unopposed, can exacerbate coronary vasoconstriction • Controversial, some centers use beta blockers • Thrombolytics • Reports of catastrophic complications when used in cocaine users (intraventricular bleed, etc.) • Lange: “Consider only after treatment with oxygen, aspirin, nitrates, and benzodiazepenes has failed

  17. Polysubstance Abuse Which of the following do you use? Tobacco Yes No Alcohol Yes No Drugs Yes No Cocaine use yesterday, EtOH every day

  18. Polysubstance Abuse • Cocaine with Alcohol • Metabolism results in the formation of Cocaethylene • Cocaethylene has similar effects to cocaine and is: • More toxic (cardio) • More stimulating to sympathetic nervous system • Has longer half-life (150 minutes vs. 40 minutes) • Cocaine with Nicotine • Nicotine increases hypertensive and tachycardic response • More rapid progression of CAD • Cocaine with Heroin • Fatal combination

  19. Case Report: Wait, there’s more • History—Vague neurologic complaints • PE—generalized left sided weakness • CT—”effacement of the posterior right insular ribbon, possible early sign of stroke” • MRI—”periventricular and subcortical white matter disease likely ischemic in nature” “advanced for this patient's age”

  20. Dedication

  21. References Burnett LB and Adler J. Cocaine. Accessed on March 3, 2006 at www.emedicine.com/emerg/topic102.htm Callaway C and Clark RF. Hyperthermia in psychostimulant overdose. Annals of Emergency Medicine. 1994; 24:68-76. Gold MS. Cocaine (and crack): clinical aspects. In: Lowinson JH, et al, eds. Substance Abuse: A Comprehensive Text. 2nd ed. Baltimore: Lippincott, Williams and Wilkins; 1992. Hollander JE, Hoffman RS, Gennis P, et al: Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med 1994 Jul-Aug; 1(4): 330-9. Jones J and Weir W. Cocaine-Associated Chest Pain. Medical Clinics of North America. 2005; 89(6): 1-13. Lange RA and Hillis LD. Cardiovascular Complications of Cocaine Use. New England Journal of Medicine. 2001; 345(5): 351-8. Mokhlesi B, et al. Street Drug Abuse Leading to Critical Illness. Intensive Care Med. 2004. 30:1526-36.

More Related