Some difficult questions:
1) If you have a cocaine toxicity case and positive cardiac enzymes (UW questions has negative enzymes), what is the next management step? decrease blood pressure with benzo or go directly to cath lab?
2) You decide to amputate a patient's leg. Who is the suitable person to put the mark on patient's leg before the OR? The physician, resident, family member or nurse?
1) You do PCI first. You treat cocaine-induced myocardial ischaemia exactly as you do non-cocaine-induced myocardial ischaemia, with the exception being you don't use beta-blockers in the former. A benzo can be helpful in getting HR and BP down, but early reperfusion is indicated.
From UpToDate:
"As in any patient with a suspected acute coronary syndrome, early reperfusion is an important part of the management of an acute coronary syndrome associated with cocaine use. In patients with STEMI and recent cocaine use, we suggest coronary angiography and primary percutaneous coronary intervention (if indicated by usual criteria) rather than fibrinolysis because of the decreased specificity of ECG findings and safety concerns (
Grade 1B). However, fibrinolytic therapy is an acceptable alternative when timely coronary angiography is not possible. As in any patient with a suspected acute coronary syndrome, early reperfusion is an important part of the management of an acute coronary syndrome associated with cocaine use (
yes, they say this sentence twice)...Benzodiazepines — Early in their care, patients with recent cocaine ingestion should receive adequate doses of benzodiazepines, as needed, for sedation and control of blood pressure and heart rate. Some patients require large cumulative doses of benzodiazepines. (See
"Cocaine: Acute intoxication", section on 'Psychomotor agitation'.)"
Notice they don't emphasize benzos at all. Not even in the summary at the end btw. They say "as needed." The answer is PCI.
2) Sounds like a stupid question. Probably whoever is doing the surgery. I'd consider the marks drawn on the skin as
part of the surgery.
