The Case of the Comatose Prisoner James Roberts, MD The Medical College of Pennsylvania/ Hahnemann University Drexel University School of Medicine Mercy Catholic Medical Center Philadelphia, Pennsylvania

James Roberts, MD Case A 28 y/o suspected cocaine dealer was involved in a police chase that ended with the suspect’s car ramming a pole. The extrication took 30 minutes due to significant vehicle damage. The man was awake at the scene and was taken to a hospital for evaluation.

James Roberts, MD Case At the hospital he had a pulse of 110/min but otherwise normal vital signs and no complaints. Other than a facial abrasion and a small scalp hematoma, the physical examination was normal. In the ED he was agitated and urinated on the floor of the examining room (“I couldn’t hold it”).

James Roberts, MD Case No laboratory tests or X rays were performed. He was observed for 2 hours, “remained stable,” and was discharged into police custody at 9pm with a diagnosis of “minor soft tissue injuries.” At the jail he was placed in a cell with 3 other prisoners. At 8am he was unarousable and was returned to the hospital.

James Roberts, MD Case Upon arrival: –Temp: 97.4 R –BP: 124/60 –Pulse: 78/min –Resp: 16/min –POx 99% on RA Monitor: sinus rhythm He was incontinent of urine Differential diagnosis at this juncture?

James Roberts, MD Differential Diagnosis Head trauma CVA Hypoglycemia/Hyperglycemia Drug Overdose (body packer, additional ingestion in jail) Post Ictal Malingering Wernicke’s encephalopathy Sepsis, CNS infection, hepatic coma, hypernatremia

James Roberts, MD Further History: No old records available No answer at home phone Police clueless Previous ED visit confirmed Next step: further evaluation/treatment

James Roberts, MD Further Examination Facial injury/scalp hematoma No Battle’s sign/ no hemotympanum Abdomen/chest/extremities demonstrated no abnormality No other signs of trauma No sign of IVDA Body habitus of chronic cocaine use What are the key components of the neurologic examination?

James Roberts, MD Neurologic Examination No response to deep pain/no posturing Pupils: 2-3 mm and sluggish Dysconjugate gaze present No gag reflex Flaccid extremities/no reflexes elicited Negative Babinski sign, no clonus, no fasciculations Outline the Basic Initial Treatment

James Roberts, MD Initial Basic Treatment Safety net: IV, Oxygen, monitor, pulse ox, dynamap Dextrostick: glucose 110 Foley catheter: clear urine ABG: pH 7.43; PO2: 145 torr on 2 liters; PCO2 42 torr; HCO3: 23 Intubated for airway protection Note: no response to above procedures, including intubation What definitive tests are required at this juncture?

James Roberts, MD Results of Tests: Head CT scan: negative CBC, Electrolytes, BUN/CR, PT/PTT : Normal Urine drug screen: (+) cocaine, (-) for barbs, benzo, opiates Serum ethanol : 10 mg% Lumbar puncture: normal opening pressure, neg chemistry/no cells EKG: Normal Liver function/ammonia: normal What therapies are reasonable?

James Roberts, MD Therapy: Probably Warranted Small dose naloxone, charcoal, thiamine Toxicology/poison center consultation Neurology consultation ICU admission

James Roberts, MD Therapy: Probably Not Warranted Flumazenil Gastric lavage/WBI Antibiotics MRI

James Roberts, MD Hospital Course Admitted to the ICU. Over the next hours the patient slowly woke up, was extubated, and admitted to a 2-week crack cocaine binge, but denied other drugs. He related numerous such “crashes” when he ran out of money for cocaine. DIAGNOSIS: The cocaine washout syndrome

James Roberts, MD Pathophysiology of the Cocaine Washout Syndrome Most likely a lack of CNS neurotransmitters –Norepinephrine –Serotonin –Dopamine

James Roberts, MD Incidence/Clinical Caveats Incidence unknown, likely quite common No data in the medical literature, but street knowledge Occurs when drug use halted (medical illness, jail, insolvent) Precipitated in ED with minimal benzodiazepine administration Vital signs normal, usually not hypotensive, bradycardic Signs of cocaine toxicity absent Patients appear in a deep sleep state Nonresponsiveness may be quite impressive

James Roberts, MD Clinical Approach Diagnosis –Clinical diagnosis/rule out other conditions –No known value of catecholamine level –Urine positive for cocaine –May require extensive, expensive R/O workup Treatment –Supportive only/protect airway and vital signs –Stimulants not warranted Course –Patients wake up slowly over hours