Morning Report 3 Neil Patel 2020

Hospital Course
● 2/13/21: brought in by EMS. 140p → 120p after 1L NS bolus

○ IV Ativan 1 mg X1ED
○ ASA 325 mg po X1ED
○ EKG - incomplete RBBB, tachycardia 128p
○ Troponin : 0.07 → 0.30 → 0.40
○ CPK: 2365 → 2400
○ IV LR 1000 @ 200 cc/hr x2 bags
● 2/14/21 : chest discomfort, SOB improving
○ Troponin : 0.40 → 0.15. No heparin gtt started
○ IV LR 1000 @ 200 cc/hr x3 bags
○ CPK : 2400 → 12475 → 9859
○ K: 3.2 : Given 60 meq KCl po. Followed by 30 meq x2 on same day
● 4 PM = left AMA. Suspected of illicit behavior, refused being searched
Complications of
Cocaine Abuse
Neil Patel, DO, PGY-1
Blake Medical Center

Background Information
● One of the most potent natural stimulants

● Erythroxylum coca = indigenous to Andes in S. America
○ Chew or brew coca tea : relieves fatigue
● First isolated in 1880s : local anesthetic in eye surgery
● Useful in ENT surgery : anesthesia + limit bleeding
● Legal and widely used in the US during 1880s - 1922
○ Main ingredient of original Coca-Cola
Pathophysiology
● Inhibition of presynaptic reuptake of NE, Epi, DA, and

serotonin
○ NE, Epi = vasoconstriction, HTN, tachycardia
○ DA = addiction
○ Serotonin = euphoria
● Stimulates release of stored neurotransmitters
● Inhibition of Na+ Channels
○ Neuronal : local anesthetic
○ Cardiac: : slows current . Overdose ⇒ wide QRS
Acute Cocaine Intoxication
● CV: arterial vasoconstriction & enhanced thrombus formation

○ Tachycardia, HTN, ↑myocardial O2 demand
○ Coronary vasoconstriction : dose-dependent
○ Cardiac ischemia: 5-6% of ED visits
○ ↑[cocaine]s ⇒ acute LV depression ⇒ acute CHF due to
negative inotropic effects (wide QRS)
● CNS : psychomotor agitation, seizures, coma, ICH, focal Sx
● Pulm : thrombus formation ⇒ pulmonary infarct (not PE)
● GI : disproportionately high rate of perforated ulcers
○ S/Sx SBO : may be body packing (smuggling)
Differential Dx for Psychomotor Agitation
● Amphetamine abuse, PCP abuse, cocaine abuse

● Hypoglycemia
● Hypoxia
● Alcohol and sedative-hypnotic withdrawal
● Serotonin syndrome
● NMS
● Heat Stroke
● Thyroid Storm
● SAH
● CNS infections
● Seizures
● Psychiatric Illness
Initial Testing
● POC Glucose - r/o other causes of AMS
● ECG
● Urine Beta-hCG in women
● CPK
● Urine Tox is NOT useful for acute toxicity, only to discover
drug use within last few days
● Trend troponins to r/o MI
● CT with con : r/o thoracic aortic dissection if Sx present
○ Severe chest/abd/upper back pain : tearing, ripping
sensation
○ SOB, stroke like sx, leg pain/difficulty ambulating
Initial Management
● Airway - Succinylcholine CIx in RSI, use non-depolarizing agent
● Psych - Diazepam 5-10 mg IV q 3-5 min
● Hypertension- Diazepam 5mg IV or Lorazepam 1mg IV q 5 min, Or
Phentolamine 1-5 mg IV prn hold if SBP <100, Beta-Blockers are CIx
to prevent unopposed α-adrenergic stimulation
● HTN emergency : goal should be to lower Diastolic pressure to 100-
105 mmHg within 2-6 hours, along with no more than an initial 25%
reduction in MAP from initial presenting value.
● Cardiac Ischemia- ECG accuracy with cocaine-associated chest pain
is unclear
○ Aspirin 325 mg PO if aortic dissection is not suspected,
Nitroglycerin 0.4mg SL
○ QRS widening on ECG is rare and suggests profound toxicity -
treat with NaBicarb 1 -2 mEq/Kg IV
Cocaine-associated chest pain (CACP)
● 40% of all ER visits related to cocaine

● Vasoconstriction and enhanced thrombus formation increase risk
of ischemia. 6% with CACP have elevated cardiac enzymes
● Most common symptoms are substernal chest pain, SOB,
tightness/pressure/squeezing, and diaphoresis.
● Always r/o MI with biomarkers. ECG has unclear accuracy in
CACP, sensitivity and specificity are 36 and 90 % respectively.
● Pneumothorax and crack lung also present with chest pain and
need to be ruled out.
● Early management includes oxygen to maintain SpO2, reduction
of sympathetic outflow using IV Benzos, add SL Nitro for patients
w/ HTN
Common Adulterants
● Levamisole : agranulocytosis, leukoencephalopathy, and

cutaneous vasculitis that can become necrotic.
○ oropharyngeal complaints, soft tissue infections and
purpura.
○ MC adulterant - used worldwide.
● Clenbuterol : a beta agonist, causes hyperglycemia and
hypokalemia,
○ tachycardia, hyperglycemia, palpitations, hypokalemia.
● Fentanyl : lethargy, respiratory depression, and pinpoint pupils.
○ Treat with naloxone.
○ Need specific assay to test for fentanyl
Disposition
● Patients with uncomplicated acute cocaine toxicity (psychomotor

agitation and sympathomimetic toxicity w/o end organ damage) :
use benzodiazepines and observation until symptoms resolve
● Patients with cocaine associated chest pain, in whom there is a

normal or unchanged ecg, and in whom thoracic dissection is not
suspected should be observed for 9-12 hours, and can be
discharged if repeat cardiac enzymes and ecg are normal.
● Patients with suspected end organ damage should be admitted.

References
https://www.uptodate.com/contents/cocaine-acute-intoxication?search=acute%20cocaine
%20intoxication&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5429517
https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-management-of-the-cardiovascular-
complications-of-cocaine-abuse?search=acute%20cocaine%20intoxication&topicRef=303&source=see_link#H8

Morning Report 3 Neil Patel 2020

Uploaded by

Copyright:

Available Formats

Morning Report 3 Neil Patel 2020

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Morning Report 3 Neil Patel 2020

Uploaded by

Copyright:

Available Formats

Hospital Course

● 2/13/21: brought in by EMS. 140p → 120p after 1L NS bolus

Blake Medical Center

● One of the most potent natural stimulants

● Inhibition of presynaptic reuptake of NE, Epi, DA, and

● CV: arterial vasoconstriction & enhanced thrombus formation

● Amphetamine abuse, PCP abuse, cocaine abuse

● 40% of all ER visits related to cocaine

● Levamisole : agranulocytosis, leukoencephalopathy, and

● Patients with uncomplicated acute cocaine toxicity (psychomotor

● Patients with cocaine associated chest pain, in whom there is a

● Patients with suspected end organ damage should be admitted.

You might also like