Cocaine and Other Sympathomimetic Objectives Understand sympathomimetic overdose pathophysiology. Presentations of sympathomimetic toxicity Diagnostic strategies of sympathomimetic toxicity Management of sympathomimetic toxicity Zohair Al Aseri MD,FRCPC EM & CCM

PERSPECTIVE Cocaine, amphetamines, and derivativesof amphetamines are called sympathomimetics. These agents cause central nervous system (CNS) stimulation and a cascade of physiologic effects. Zohair Al Aseri MD,FRCPC EM & CCM

CLINICAL EFFECTSOF SYMPATHOMIMETICS Zohair Al Aseri MD,FRCPC EM & CCM

Pathophysiology of Cocaine PRINCIPLES OF DISEASE Pathophysiology of Cocaine Acute cocaine use causes release of dopamine, epinephrine, norepinephrine, and serotonin. These neurotransmitters most important effects are adrenergic stimulation by norepinephrine and epinephrine. Norepinephrine causes vasoconstriction by stimulating alpha-adrenergic receptors on vascular smooth muscle. Zohair Al Aseri MD,FRCPC EM & CCM

How cocaine increases sympathetic tone by increasing neurotransmitters in the synapse. Zohair Al Aseri MD,FRCPC EM & CCM

Pathophysiology of Cocaine PRINCIPLES OF DISEASE Pathophysiology of Cocaine Sodium channel blockade across myocardial cells, is responsible for the occasional conduction abnormality with acute cocaine toxicity. Cocaine metabolism occurs in the liver and the plasma. Use of ethanol with cocaine may form cocaethylene, a metabolite that may potentiate the drug's stimulatory effects. Zohair Al Aseri MD,FRCPC EM & CCM

Cocaine Formulations The water-soluble salts of cocaine (cocaine hydrochloride and cocaine sulfate) are available as a white crystalline powder that is taken intranasally or dissolved and injected intravenously. Oral administration is rare except for patients who are smuggling or concealing drugs. Zohair Al Aseri MD,FRCPC EM & CCM

Cocaine Pharmacology by Routeof Administration Zohair Al Aseri MD,FRCPC EM & CCM

CLINICAL FEATURES Excitation of the sympathetic nervous system. Diaphoresis, tachycardia, mydriasis, and hypertension without organ damage. If severely intoxicated may present agitated, combative, and hyperthermic. Signs and symptoms of end-organ damage may be present, including acute hypertensive emergencies. Focal, acute pain syndromes. Circulatory abnormalities. Delirium; or seizures. Zohair Al Aseri MD,FRCPC EM & CCM

Hypertensive emergencies Cardiac dysrhythmias. Initial assessment and treatment should focus on rapidly fatal complications Hyperthermia Hypertensive emergencies Cardiac dysrhythmias. Zohair Al Aseri MD,FRCPC EM & CCM

Hyperthermia Agitation with delirium increases the risk of hyperthermia. Increased motor tone and generate heat. Delay in recognition result in death. Increased motor tone can release intramuscular (CK) with rhabdomyolysis and its attendant renal and electrolyte complications. Zohair Al Aseri MD,FRCPC EM & CCM

Hypertensive Emergencies Sequelae include Aortic dissection Pulmonary edema Myocardial ischemia and infarction Intracranial hemorrhage, strokes Infarction of the anterior spinal artery. Intestinal infarctions and mesenteric ischemia Retinal vasospasm, Renal infarctions Placental insufficiency and gravid uterus infarction Zohair Al Aseri MD,FRCPC EM & CCM

Cardiac Dysrhythmias Sinus tachycardia is most common Atrial fibrillation and other supraventricular tachycardias Torsades de pointes or wide-complex tachycardias from blockade of fast sodium channels Hyperkalemia from rhabdomyolysis and myocardial ischemia can also cause dysrhythmias. Zohair Al Aseri MD,FRCPC EM & CCM

Other Complications Oropharyngeal burns from the high temperature required to volatilize the drug. Pneumothorax, pneumopericardium, and pneumomediastinum occur from inhalational barotrauma. Intranasal cocaine use is associated with sinusitis and naso palatine necrosis or perforation. Intravenous users have a high risk of infection with blood-borne viruses, local abscesses, and systemic bacterial infections, including botulism, and endocarditis. Zohair Al Aseri MD,FRCPC EM & CCM

DIAGNOSTIC STRATEGIES Urine drug screening is unlikely to change treatment because it measures a cocaine metabolite (benzoyl ecgonine) that is typically present for 3 days after last use. Urine drug screening may be beneficial in (1) to document possible abuse or neglect in a child with suggested exposure (2) to confirm cocaine as the unknown substance in body packers (3) to differentiate paranoia from drug-induced or psychiatric causes. Zohair Al Aseri MD,FRCPC EM & CCM

DIAGNOSTIC STRATEGIES ECG screens for Dysrhythmias conduction abnormalities hyperkalemia ECG Signs Creatine kinase (CK) serum CK-MB fraction, troponin I, and troponin T are more specific in patients with atherogenic coronary disease CT Brain For sever headache Zohair Al Aseri MD,FRCPC EM & CCM

DIFFERENTIAL CONSIDERATIONS Sedative-hypnotic withdrawal Amphetamines and its derivatives Heatstroke Infection Zohair Al Aseri MD,FRCPC EM & CCM

INITIAL EVALUATION OF PATIENTS WITH SYMPATHETIC STIMULATION Zohair Al Aseri MD,FRCPC EM & CCM

MANAGEMENT After initial airway assessment physical restraints to obtain complete vital signs and to secure IV access. If a chest restraint is used, a mesh vest is preferred to a jacket to help limit hyperthermia. Empirical therapy with IV dextrose and thiamine or assessment with a bedside blood glucose monitor. IV benzodiazepines may be necessary Zohair Al Aseri MD,FRCPC EM & CCM

MANAGEMENT OF STIMULANT-INDUCED HYPERTHERMIA Zohair Al Aseri MD,FRCPC EM & CCM

NO B Blockers Hypertensive Emergencies Benzodiazepines restore the CNS inhibitory tone on the peripheralnervous system. With evidence of end-organ damage, IV nitroglycerin or nitroprusside can be used. NO B Blockers Zohair Al Aseri MD,FRCPC EM & CCM

Dysrhythmias When the cause of a wide-complex tachycardia from cocaine is unknown, an empirical sodium bicarbonate, 1 to 2 mEq/kg IV bolus Treats sodium channel blockade and potential cardiotoxicity from hyperkalemia. Zohair Al Aseri MD,FRCPC EM & CCM

CAUSES OF STIMULANT-INDUCED CHEST PAIN Zohair Al Aseri MD,FRCPC EM & CCM

Cocaine Body Packers A body packer may present without symptoms to the ED. The body packer should be placed immediately on continuous cardiac monitoring, with large- bore IV access. An abdominal radiograph may confirm foreign bodies When uncertainty persists, a contrast study is warranted. Zohair Al Aseri MD,FRCPC EM & CCM

Cocaine Body Packers Body packing also is used for transporting heroin and other illicit substances. A urine toxicology screen may be useful because some fine quantities of drug may be directly ingested while swallowing the contraband. Body packers with a positive urine screen for cocaine metabolites should receive vigorous decontamination. Zohair Al Aseri MD,FRCPC EM & CCM

Cocaine Body Packers Rupture of a single cocaine packet can result in death because each packet contains almost 10 times the lethal dose. All cocaine body packers should be admitted to a monitored setting and given nothing to eat or drink. Patients with a leaking or poorly secured packet who become symptomatic needs immediate surgical removal of packets. Zohair Al Aseri MD,FRCPC EM & CCM

Body Stuffers A “body stuffer” is an individual who attempts to conceal evidence of cocaine possession by swallowing the drug while pursued by law enforcement officials. The drugs are often swallowed in poorly sealed vials or glassine packets that may not be evident on radiographs. Zohair Al Aseri MD,FRCPC EM & CCM

Body Stuffers Generally, patients ingest nonlethal doses and are asymptomatic. Activated charcoal (50 g) can absorb any potentially released drug. Monitoring and whole-bowel irrigation should be performed if the quantity ingested is of concern or if signs of intoxication persist. Zohair Al Aseri MD,FRCPC EM & CCM

DISPOSITION can be discharged after the acute intoxication resolves. Patients may be extremely sleepy from catecholamine depletion, and it is best to discharge them with a responsible adult. Patients who develop complications should bead mitted to ICU for further treatment. Zohair Al Aseri MD,FRCPC EM & CCM

ADMISSION CRITERIA FOR COCAINE-RELATED CHEST PAIN Zohair Al Aseri MD,FRCPC EM & CCM

DISPOSITION Patients with chest pain should be admitted. Aftera 12-hour monitored observation period, patients with a benign clinical course and negative serum enzyme markers can be discharged. Zohair Al Aseri MD,FRCPC EM & CCM