cocaine chest pain

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LotaPower

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How do you guys usually handle these people.

if they're < 40 y.o. with few risk factors, i get a baseline ekg. if it's normal, i give them benzos and send them home. if they're > 40, or have >1 risk factor or if they have any contiguous changes, ill send trops and treat them like any other chest pain pt, and admit them

i've seen people do it this way but i've even seen many people blow off cocaine chest pain, give them benzos and kick them out attitude, sometimes without even an EKG.

where is the medium?

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No matter the age, if chest pain and cocaine use (recently, ie temporally related). All get EKG, all get set of enzymes, benzo. especially if evidene of sympathomimetic (htn, tachy).

sometimes if they're older we'll do 2 sets of enzymes and boot 'em.

IIRC, the incidence of true MI in the setting of cocaine is around 5-6%.

correct me if I'm wrong.

later
 
that's correlates with what I've read as well. 6% of people with cocaine chest pain will rule in for a NSTEMI. cocaine accelerates CAD, work them up for it.
 
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8-hour obs, 2 negative troponins, go home. All comers.
 
I agree with the above statement, however in the urban environment in which I currently train, everyone has risk factors and we have no room for mistakes.

Everyone gets OBS'd overnight (This amounts to about a 12-18 hour stay in the observation unit) and most get stressed the next day.
 
Do you check drug tests on everyone with chest pain?

It raises a liability issue if they come back positive for cocaine. If they adamantly deny cocaine, I don't typically test for it unless there are other clinical clues.
 
Do you check drug tests on everyone with chest pain?

It raises a liability issue if they come back positive for cocaine. If they adamantly deny cocaine, I don't typically test for it unless there are other clinical clues.

I get UDS (so does everyone else where I'm at) on ALL chest pains. Where I work.........1. everyone does crack, young, old, black and white. 2. I never ever ever believe or trust my patients.

Now number 2 is only for my training facility (urban, county hospital). I've been burned too many times to listen to "I can't POSSIBLY be pregnant Doctor", "I've NEVER done drugs." "I've never had any surgery" only to see zipper on chest.

Where I moonlight I MIGHT believe them more (suburbuan, have doctors, and jobs). I still don't believe any woman on the pregnancy thing, but might on the cocaine thing.

I not only think it is helpful in the workup of chest pain as far as potential etiology and treatment (benzos), but nice for PCP and cards when they discharge these guys and want to put them on a beta blocker etc...

later
 
Everyone gets OBS'd overnight (This amounts to about a 12-18 hour stay in the observation unit) and most get stressed the next day.

What about when these folks are repeat offenders?
 
What about when these folks are repeat offenders?

They suck, but what are you going to do?

We have many that are literally daily complaint folks.


They still get their ekg and enzymes, frequently are dc from ER after 1 or 2 sets of neg enzymes.

later
 
What about when these folks are repeat offenders?

Repeat offenders still go to the OBS unit. Stress tests typically are good for 6 months in my institution. If they've ever bumped there enzymes or had significant EKG changes, cardiology was consult. In those cases, they go to OBS with a cardiology consult. Repeat offenders who are seen by Cardiology enough will eventually get a CATH. I can't figure out how long a CATH is good for because each Cardiologist does something different. I would estimate at least 1 to 1.5 years.

I say these patients go to our OBS unit because they typically come in sometime after 8 pm. In our OBS unit, pts. are not discharged until at least 10 am.

JJ
 
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