COCAINE 101 for the (E)Medical Student

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COCAINE 101for the (E)Medical Student

• Brigham Dastrup, BA
• March 7, 2006

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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
• EKGno changes from previous study
• Cardiac enzymesnegative x3
• Chest X-ray unremarkable

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Differential Diagnosis

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

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The Rest of the Story

• Which of the following do you use?
• Tobacco Yes No
• Alcohol Yes No
• Drugs Yes No

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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

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Back to the Differential

• NSTEMI
• PE
• Pneumothorax
• Pneumonia
• Anxiety
• Endocarditis
• Aortic Dissection
• Cocaine Chest Pain???
• First some background. . .

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Brief History of Cocaine

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

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Brief History of Cocaine

• 1885John 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

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Cocaine Terminology for Dummies

• Body packercarefully wraps packages and uses GI
  tract as hiding place for drug transport
• Body stuffersimilar to packer but done more
  quickly (less safely) when faced with police,
  etc.
• CrackCocaine HCl concentrated by heating the
  drug in baking soda until water evaporates name
  comes from cracking sound made when heated

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Cocaine Terminology for Dummies

• Cut drugsdrugs mixed with other similar
  appearing substances (clinical significance)
• Slammed cocainecocaine used IV
• SPEEDBALLheroin injected or snorted followed
  immediately by smoking of cocaine

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Back to Cocaine in the ER

• Powerful stimulant of the sympathetic NS
• Signs of Cocaine Use
• Tachycardia
• Dilated Pupils
• Hypertension
• Hyperthermia
• Profuse Diaphoresis
• Agitation

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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 (45.6C114F!!)
• Etc.etc.etc.

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A few specifics. . .

• Chest PainMost 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

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Cocaine Chest Pain Challenges

• EKG
• High failure rate in detecting MI (Sens36)
• 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

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Cocaine Chest Pain Treatment

• Nitroglycerin/Verapamilreverse cocaine-induced
  HTN and vasoconstriction of coronary arteries
• AspirinInhibit Platelet aggregation
• Benzosreduced heart rate, blood pressure, may
  attenuate cocaines toxic effects on heart and
  nervous system
• Phentolaminereverses vasoconstriction of
  coronaries

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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

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Polysubstance Abuse

• Which of the following do you use?
• Tobacco Yes No
• Alcohol Yes No
• Drugs Yes No
• Cocaine use yesterday, EtOH every day

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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

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Case Report Wait, theres more

• HistoryVague neurologic complaints
• PEgeneralized left sided weakness
• CTeffacement of the posterior right insular
  ribbon, possible early sign of stroke
• MRIperiventricular and subcortical white matter
  disease likely ischemic in nature advanced for
  this patient's age

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Dedication
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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 2468-76. 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. 301526-36.