COCAINE 101COCAINE 101for the (E)Medical for the (E)Medical

Student Student

Brigham Dastrup, BABrigham Dastrup, BA

March 7, 2006March 7, 2006

Case PresentationCase Presentation 44yo female with h/o HTN presents with 44yo female with h/o HTN presents with

24 hour acute exacerbation of chronic 24 hour acute exacerbation of chronic substernal chest pain. Chest pain not substernal chest pain. Chest pain not exertional. She describes radiation to her exertional. She describes radiation to her left arm. (+) dyspnea (baseline) left arm. (+) dyspnea (baseline) (-)Nausea/vomiting, (-) diaphoresis(-)Nausea/vomiting, (-) diaphoresis

““Very high” blood pressure at outside Very high” blood pressure at outside medical centermedical center

““3 valves are blocked” possible CAD3 valves are blocked” possible CAD EKG—no changes from previous studyEKG—no changes from previous study Cardiac enzymes—negative x3Cardiac enzymes—negative x3 Chest X-ray unremarkableChest X-ray unremarkable

Differential DiagnosisDifferential Diagnosis

MIMI PEPE PneumothoraxPneumothorax PneumoniaPneumonia AnxietyAnxiety EndocarditisEndocarditis Aortic DissectionAortic Dissection

Wait a minute, I forgot to tell you Wait a minute, I forgot to tell you something. . . .something. . . .

The Rest of the StoryThe Rest of the Story

Which of the following do you use?Which of the following do you use?

TobaccoTobacco YesYes NoNo

AlcoholAlcohol YesYes NoNo

DrugsDrugs YesYes NoNo

The Rest of the StoryThe Rest of the Story

Which of the following do you use?Which of the following do you use?

TobaccoTobacco YesYes NoNo

AlcoholAlcohol YesYes NoNo

DrugsDrugs YesYes NoNo

Cocaine use yesterday, EtOH every Cocaine use yesterday, EtOH every dayday

Back to the DifferentialBack to the Differential NSTEMINSTEMI PEPE PneumothoraxPneumothorax PneumoniaPneumonia AnxietyAnxiety EndocarditisEndocarditis Aortic DissectionAortic Dissection Cocaine Chest Pain???Cocaine Chest Pain???

First some background. . .First some background. . .

Brief History of CocaineBrief History of Cocaine

Ancient Incas believed cocaine to be a Ancient Incas believed cocaine to be a gift from the godsgift from the gods

1884—William Halsted performed the 1884—William Halsted performed the first nerve block using cocaine as the first nerve block using cocaine as the anesthetic, eventually became anesthetic, eventually became dependentdependent

Same year—Sigmund Freud publishes Same year—Sigmund Freud publishes article on cocaine, advocates its use in article on cocaine, advocates its use in the treatment of asthma, wasting the treatment of asthma, wasting diseases and syphilis, also became diseases and syphilis, also became dependentdependent

Brief History of CocaineBrief History of Cocaine• 1885—John

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

Cocaine Terminology for Cocaine Terminology for DummiesDummies

Body packer—carefully wraps packages and Body packer—carefully wraps packages and uses GI tract as hiding place for drug transportuses GI tract as hiding place for drug transport

Body stuffer—similar to packer but done more Body stuffer—similar to packer but done more quickly (less safely) when faced with police, quickly (less safely) when faced with police, etc.etc.

Crack—Cocaine HCl concentrated by heating Crack—Cocaine HCl concentrated by heating the drug in baking soda until water the drug in baking soda until water evaporates; name comes from “cracking” evaporates; name comes from “cracking” sound made when heatedsound made when heated

Cocaine Terminology for Cocaine Terminology for DummiesDummies

Cut drugs—drugs mixed with other similar Cut drugs—drugs mixed with other similar appearing substances appearing substances (clinical (clinical significance)significance)

Slammed cocaine—cocaine used IVSlammed cocaine—cocaine used IV

SPEEDBALL—heroin injected or snorted SPEEDBALL—heroin injected or snorted followed immediately by smoking of followed immediately by smoking of cocainecocaine

Back to Cocaine in the ER Back to Cocaine in the ER

Powerful stimulant of the sympathetic Powerful stimulant of the sympathetic NSNS

Signs of Cocaine UseSigns of Cocaine Use– TachycardiaTachycardia– Dilated PupilsDilated Pupils– HypertensionHypertension– HyperthermiaHyperthermia– Profuse DiaphoresisProfuse Diaphoresis– AgitationAgitation

ER Presentation of Cocaine ER Presentation of Cocaine UseUse

CardiacCardiac

– Chest painChest pain -MI-MI

– ArrythmiasArrythmias --CardiomyopathyCardiomyopathy

Vascular (spasms)Vascular (spasms)

– BlindnessBlindness -Renal Infarction-Renal Infarction

– Limb Ischemia -Intestinal IschemiaLimb Ischemia -Intestinal Ischemia

– Aortic DissectionAortic Dissection

RespiratoryRespiratory

– PneumothoraxPneumothorax

– Pulmonary hemorrhage/infarctionPulmonary hemorrhage/infarction

– Diffuse Alveolar HemorrhageDiffuse Alveolar Hemorrhage

– Pulmonary EdemaPulmonary Edema

– Asthma ExacerbationAsthma Exacerbation

– Eosinophilic Lung Disease etc. etc.Eosinophilic Lung Disease etc. etc.

NeurologicNeurologic

– CVACVA -Seizures -Seizures

– ““crack dancing” extrapyramidal crack dancing” extrapyramidal sxssxs

MetabolicMetabolic

– Hyperglycemia - AcidosisHyperglycemia - Acidosis

– HyperkalemiaHyperkalemia

OphthalmologicOphthalmologic

– Cerebral vasculitisCerebral vasculitisdecreased decreased visual acuity or blindnessvisual acuity or blindness

– Numerous other problemsNumerous other problems

Excited/Agitated DeliriumExcited/Agitated Delirium

Hyperthermia (45.6C—Hyperthermia (45.6C—114F!!)114F!!)

Etc.etc.etc.Etc.etc.etc.

A few specifics. . . A few specifics. . . Chest Pain—Most common ER complaint Chest Pain—Most common ER complaint

associated with cocaine useassociated with cocaine use– Dr. Richard Lange study: “Of patients who Dr. Richard Lange study: “Of patients who

come to the emergency department with come to the emergency department with nontraumatic chest pain, 14-25% in urban nontraumatic chest pain, 14-25% in urban hospitals. . .have detectable levels of cocaine hospitals. . .have detectable levels of cocaine or cocaine metabolites in their blood”or cocaine metabolites in their blood”

– Above study cautions that cocaine must be Above study cautions that cocaine must be seriously considered in differential for chest seriously considered in differential for chest pain especially in patients with few other risk pain especially in patients with few other risk factors for atherosclerosisfactors for atherosclerosis

Cocaine Chest Pain Cocaine Chest Pain Challenges Challenges

EKGEKG– High failure rate in detecting MI (Sens—36%)High failure rate in detecting MI (Sens—36%)– 43% of cocaine abusers 43% of cocaine abusers withoutwithout myocardial myocardial

infarction meet EKG criterion for initiation of infarction meet EKG criterion for initiation of reperfusion therapy (ST elev. in 2 contiguous reperfusion therapy (ST elev. in 2 contiguous leads)leads)

Creatine kinaseCreatine kinase– Elevated in half of cocaine users who do not Elevated in half of cocaine users who do not

have MIhave MI– Troponin more reliableTroponin more reliable

Cocaine Chest Pain Cocaine Chest Pain Treatment Treatment

Nitroglycerin/Verapamil—reverse Nitroglycerin/Verapamil—reverse cocaine-induced HTN and cocaine-induced HTN and vasoconstriction of coronary arteriesvasoconstriction of coronary arteries

Aspirin—Inhibit Platelet aggregationAspirin—Inhibit Platelet aggregation Benzos—reduced heart rate, blood Benzos—reduced heart rate, blood

pressure, may attenuate cocaine’s toxic pressure, may attenuate cocaine’s toxic effects on heart and nervous systemeffects on heart and nervous system

Phentolamine—reverses Phentolamine—reverses vasoconstriction of coronariesvasoconstriction of coronaries

Cocaine Chest Pain Cocaine Chest Pain Treatment Treatment

Beta-blockers, best Beta-blockers, best notnot to use to use– Selective beta block leaves alpha1 tone Selective beta block leaves alpha1 tone

unopposed, can exacerbate coronary unopposed, can exacerbate coronary vasoconstrictionvasoconstriction

– Controversial, some centers use beta blockersControversial, some centers use beta blockers

ThrombolyticsThrombolytics– Reports of catastrophic complications when Reports of catastrophic complications when

used in cocaine users (intraventricular bleed, used in cocaine users (intraventricular bleed, etc.)etc.)

– Lange: “Consider only after treatment with Lange: “Consider only after treatment with oxygen, aspirin, nitrates, and oxygen, aspirin, nitrates, and benzodiazepenes has failedbenzodiazepenes has failed

Polysubstance Abuse Polysubstance Abuse

Which of the following do you use?Which of the following do you use?

TobaccoTobacco YesYes NoNo

AlcoholAlcohol YesYes NoNo

DrugsDrugs YesYes NoNo

Cocaine use yesterday, EtOH every Cocaine use yesterday, EtOH every dayday

Polysubstance Abuse Polysubstance Abuse Cocaine with AlcoholCocaine with Alcohol

– Metabolism results in the formation of Metabolism results in the formation of CocaethyleneCocaethylene

– Cocaethylene has similar effects to cocaine and is:Cocaethylene has similar effects to cocaine and is: More toxic (cardio)More toxic (cardio) More stimulating to sympathetic nervous systemMore stimulating to sympathetic nervous system Has longer half-life (150 minutes vs. 40 minutes)Has longer half-life (150 minutes vs. 40 minutes)

Cocaine with NicotineCocaine with Nicotine– Nicotine increases hypertensive and tachycardic Nicotine increases hypertensive and tachycardic

responseresponse

– More rapid progression of CADMore rapid progression of CAD

Cocaine with HeroinCocaine with Heroin– Fatal combinationFatal combination

Case Report: Wait, there’s Case Report: Wait, there’s more more

History—Vague neurologic complaintsHistory—Vague neurologic complaints PE—generalized left sided weaknessPE—generalized left sided weakness CT—”effacement of the posterior right CT—”effacement of the posterior right

insular ribbon, possible early sign of insular ribbon, possible early sign of stroke” stroke”

MRI—”periventricular and subcortical MRI—”periventricular and subcortical white matter disease likely ischemic in white matter disease likely ischemic in nature” “advanced for this patient's nature” “advanced for this patient's age”age”

DedicationDedication

ReferencesReferencesBurnett LB and Adler J. Cocaine. Accessed on March 3, 2006 at Burnett LB and Adler J. Cocaine. Accessed on March 3, 2006 at

www.emedicine.com/emerg/topic102.htmwww.emedicine.com/emerg/topic102.htm

Callaway C and Clark RF. Hyperthermia in psychostimulant overdose. Callaway C and Clark RF. Hyperthermia in psychostimulant overdose. Annals of Emergency MedicineAnnals of Emergency Medicine. 1994; 24:68-76.. 1994; 24:68-76.

Gold MS. Cocaine (and crack): clinical aspects. In: Lowinson JH, et al, eds. Gold MS. Cocaine (and crack): clinical aspects. In: Lowinson JH, et al, eds. Substance Abuse: A Comprehensive Text. 2Substance Abuse: A Comprehensive Text. 2ndnd ed. Baltimore: Lippincott, ed. Baltimore: Lippincott, Williams and Wilkins; 1992.Williams and Wilkins; 1992.

Hollander JE, Hoffman RS, Gennis P, et al: Prospective multicenter Hollander JE, Hoffman RS, Gennis P, et al: Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med 1994 Jul-Aug; 1(4): 330-9. Pain (COCHPA) Study Group. Acad Emerg Med 1994 Jul-Aug; 1(4): 330-9.

Jones J and Weir W. Cocaine-Associated Chest Pain. Jones J and Weir W. Cocaine-Associated Chest Pain. Medical Clinics of North Medical Clinics of North AmericaAmerica. 2005; 89(6): 1-13.. 2005; 89(6): 1-13.

Lange RA and Hillis LD. Cardiovascular Complications of Cocaine Use. Lange RA and Hillis LD. Cardiovascular Complications of Cocaine Use. New New England Journal of MedicineEngland Journal of Medicine. 2001; 345(5): 351-8.. 2001; 345(5): 351-8.

Mokhlesi B, et al. Street Drug Abuse Leading to Critical Illness. Mokhlesi B, et al. Street Drug Abuse Leading to Critical Illness. Intensive Intensive Care MedCare Med. 2004. 30:1526-36.. 2004. 30:1526-36.