Cocaine

[cbrons]

Concerning cocaine/sympathomimetic overdose...I am working on an assignment right now with an EM attending at my institution, and have read the textbooks on this issue but am now wondering about the real world. Is there anything that makes these patients hard to recognize or treat?

Will also take any anecdotes concerning pediatric or pregnant patients.

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[Hair Police]

If you're asking that kind of question, I would reconsider participating in the project.

 

[cbrons]

If you're asking that kind of question, I would reconsider participating in the project.

I dont have a choice, but ty?

 

[Daiphon]

Not sure I understand the query. The beauty of any autonomic poison is symptoms cannot be hidden. You're either sympathomimetic or you're not (unless you're anticholinergic, but I digress).

Are you inquiring as to what other agents can cause sympathomimesis? Are you asking if cocaine has a specific calling card that distinguishes it from other adrenergic stimulants? Are you asking us to do your homework for you?

 

[WilcoWorld]

Cocaine toxicity = Ativan deficiency

Unless you're getting into sodium channelopathies (in which case I'll defer to my local Diaphon), that's all the cocaine-related toxicology you need to know.

 

[cbrons]

Cocaine toxicity = Ativan deficiency

Unless you're getting into sodium channelopathies (in which case I'll defer to my local Diaphon), that's all the cocaine-related toxicology you need to know.

So do most people respond to benzos or have you seen people who required additional treatment ie. phentolamine or nitroglycerin or something to alleviate their drug induced ACS?

 

[racerwad]

You could use NTG as in normal ACS. Intracoronary NTG can be/has been used in cocaine ODs that are causing refractory vasospasm, but obviously that's not an EM thing. As others have mentioned: benzos and benzos and benzos. Probably the only pitfall is using beta-blockers, so don't do that (unopposed alpha agonism, etc).

 

[link2swim06]

So do most people respond to benzos or have you seen people who required additional treatment ie. phentolamine or nitroglycerin or something to alleviate their drug induced ACS?

They will feel better with benzo sedation. Some higher doses than others. Remember they can vasospasm across across real CAD. Just because it is cocaine chest pain doesn't mean they don't have actual problems.

I have never seen phentolamine used. Use more benzos. If they are going crazy they may need a little haldol too.

We don't use beta-blockers because some obscure animal based study before any of us were born talking about "unopposed alpha."

 

[njac]

Also: phentolamine has been on shortage forever and only recently started to be manufactured again - but for how long?

http://www.ashp.org/menu/DrugShortages/DrugsNoLongerAvailable/bulletin.aspx?id=349

 

[sluggs]

DO NOT USE BETA BLOCKERS. Trust me. Unopposed alpha is real. Saw a guy stroke once.
Benzos=good

 

[gro2001]

There is also this interesting study that shows correlation between ambient temperature and cocaine related death in NYC:

http://www.ncbi.nlm.nih.gov/pubmed/20219056

 

[alpinism]

The few cases i've been a part of ativan and nitroglycerin seemed to work well.

Always be on the lookout for co-ingestions though (see: speedball). This is when it gets tricky since the patients can present without the classic toxidrome symptoms or transition from stimulant to depressant symptoms before they stop breathing.

The cocaine population (at least around these parts) very commonly uses multiple drugs during binges.

 

[deleted547339]

DO NOT USE BETA BLOCKERS. Trust me. Unopposed alpha is real. Saw a guy stroke once.
Benzos=good

Anecdote alert.

 

[Old_Mil]

If there is anything that might throw you for a loop it is a contaminant or a coingestion. Otherwise it is pretty straightforward. Remember that it may be the drug screen and not the history that gives you the truth about what illegal drugs a patient is taking.

Sent from my SM-T900 using Tapatalk

 

[Apollyon]

Anecdote alert.

So what? If it happened to one guy, I am not going to be the idiot that tempts fate. There are more than enough land mines to keep me worried, beyond adding a complication of my own choice.

I was doing a CME conference in June, and one of the people speaking was recounting a story of a colleague that gave a patient the bottle of tetracaine to go, and the pt wore their cornea away. He was sued, and lost. And, yet, the guy still does it. Defies logic. I take others stories as my own, so that I don't do it.

 

[deleted547339]

So what? If it happened to one guy, I am not going to be the idiot that tempts fate. There are more than enough land mines to keep me worried, beyond adding a complication of my own choice.

I was doing a CME conference in June, and one of the people speaking was recounting a story of a colleague that gave a patient the bottle of tetracaine to go, and the pt wore their cornea away. He was sued, and lost. And, yet, the guy still does it. Defies logic. I take others stories as my own, so that I don't do it.

I get what you're saying, but I disagree.

 

[Apollyon]

I get what you're saying, but I disagree.

All I'm going to say is that, if you come outright and say that you are going to give beta blockade to cocaine OD, then I am going to think you are either reckless, or stubborn.

If you are expecting RCTs, recall the study about parachutes - they've never been statistically proven to save lives.

 

[Daiphon]

All I'm going to say is that, if you come outright and say that you are going to give beta blockade to cocaine OD, then I am going to think you are either reckless, or stubborn.

If you are expecting RCTs, recall the study about parachutes - they've never been statistically proven to save lives.

Beta blockade in cocaine intoxication/OD is a relative CI based on some really old and wonky studies.

The question is this: is the CP vasospastic (in which case avoidance may be prudent) or rate related +/- fixed obstruction (cocaine accelerates atherosclerosis) - in which case rate control may be beneficial. Short of bedside angios, there's no reliable way to predict.

So, if you're gonna BB, then either use labetalol (alpha activity) or esmolol (can be turned off PDQ).

Or just benzo the excrement out of them. d=)

It's a sticky wicket without great answers.

-d

 

[Hair Police]

I dont have a choice, but ty?

If you're asking this question, it means your local incidence of these patients is low and therefore unlikely to be a good population to study in your ED. A quick query of your EMR for "agitation" or "cocaine toxicity" would help give you an idea of how many patients your ED sees. Given an incidence and a power calculation, you can determine how many patients your study needs and how long you'll have to enroll. But from your post, it doesn't seem like you have a defined objective, let alone a hypothesis.

So without a solid plan or a relevant patient population, a hard job (i.e., successfully conducting a research project as a busy resident) has been made much more difficult. If you're at the beginning stages, I'd rethink the whole thing. I generally advise residents to only consider projects that fall into one of two groups - retrospective studies (cheap, fast, and the data has already been collected) and studies of normal adults because you can enroll your resident colleagues.

 

[Hair Police]

...If you are expecting RCTs, recall the study about parachutes - they've never been statistically proven to save lives.

The parachute study was meant as a joke because we shouldn't need evidence for things that are patently obvious. It was not meant to justify a position of intentional ignorance.

There are a number of things we do where there won't be a study for clear ethical reasons because the efficacy of the intervention is assumed. Antibiotics vs placebo for presumed bacterial infections. Rates of preventable disease in vaccinated and unvaccinated children. Blood transfusions. Parachutes and jumping out of planes. But for the things we can study, we should know whether they work or not. To do otherwise would be a disservice to our patients. I give benzos to agitated patients - because that's all they need - but we should encourage people to question the status quo. Off the top of my head, the history of radical mastectomy and internal mammary ligation are two examples why.

 

[cbrons]

If you're asking this question, it means your local incidence of these patients is low and therefore unlikely to be a good population to study in your ED. A quick query of your EMR for "agitation" or "cocaine toxicity" would help give you an idea of how many patients your ED sees. Given an incidence and a power calculation, you can determine how many patients your study needs and how long you'll have to enroll. But from your post, it doesn't seem like you have a defined objective, let alone a hypothesis.

So without a solid plan or a relevant patient population, a hard job (i.e., successfully conducting a research project as a busy resident) has been made much more difficult. If you're at the beginning stages, I'd rethink the whole thing. I generally advise residents to only consider projects that fall into one of two groups - retrospective studies (cheap, fast, and the data has already been collected) and studies of normal adults because you can enroll your resident colleagues.

this isnt a research project, its a simple presentation I have to give.

 

[Hair Police]

this isnt a research project, its a simple presentation I have to give.

Ah. Then carry on.

 

[Apollyon]

The parachute study was meant as a joke because we shouldn't need evidence for things that are patently obvious. It was not meant to justify a position of intentional ignorance.

There are a number of things we do where there won't be a study for clear ethical reasons because the efficacy of the intervention is assumed. Antibiotics vs placebo for presumed bacterial infections. Rates of preventable disease in vaccinated and unvaccinated children. Blood transfusions. Parachutes and jumping out of planes. But for the things we can study, we should know whether they work or not. To do otherwise would be a disservice to our patients. I give benzos to agitated patients - because that's all they need - but we should encourage people to question the status quo. Off the top of my head, the history of radical mastectomy and internal mammary ligation are two examples why.

"Intentionally ignorant" - really, thank you for that. I'm being painted into a corner here, just because I am not willing to be the dummy that makes a left turn, because I can.

I really don't care what someone else does - and, if it bites them in the ass, well, that is clearly on them. All I want is for that problem not to be there for me when I am there. If it comes back on the next shift, or tomorrow, when I am not there, I am fine with that.

I only have my own practice pattern as a dog in this fight. Whatever.

However, as an ancillary question, are those BMJ end of year papers real papers that are absurd, or are they strictly made up from whole cloth, as comedy? That's because they look substantial enough, but espouse trivial points.