Cocaine Track D September 17, 2003 Barcelona Lewis R. Goldfrank, MD Professor and Chairman of Emergency Medicine New York University Medical Center Bellevue Hospital Center New York University School of Medicine Medical Director, New York City Poison Center

Case 1 A twenty year old man is brought to the ED by ten New York City police in a body bag. He is uncontrollably agitated. He is diffusely diaphoretic with RR 24, HR 160, BP160/120. What should be done?

Physical  wet packs, restraining chairs  nets, straight jackets, restraints Chemical  bromides, antihistamines, morphine  paraldehyde, chloral hydrate, ethanol  antipsychotics: phenothiazines/butyrophenones  barbiturates  benzodiazepines: diazepam, oxazepam, lorazepam, midazolam   -Adrenergic antagonists, a 2 adrenergic agonists History Therapeutic Interventions for the Agitated Patient

Physical restraints only serve to temporize, while awaiting chemical restraints. Struggle against physical restraints may lead to fatal hyperthermic events

Avoid vinyl “body-bags” Avoid cervical collars when not indicated Mesh or netting restraints work Use restraining devices that Will allow for heat dissipation Control the Situation

Do not attempt to restrain an agitated patient until you have them thoroughly outnumbered A. Limits the risk of harm to yourself B. Rapidly controls the patient in order to minimize the risk of patient trauma

Control the Situation Proper restraint requires at least five to six rescuers A. One person handles each extremity B. One person manages the head and airway C. One person coordinates the activity D. Universal precautions should be utilized at all times

 One hand just proximal and one hand just distal to the joint  Immobilize both elbows and knees in extension  Restricts movement.

Team leader secures the patient’s head by grasping the forehead with one hand and securing the chin with the other.

 Check each limb for discoloration and any compromise of pulse and capillary refill.  Must be able to place two fingers under the restraint.  Patient’s face, mouth, and neck must not be covered or restrained.

Control the Situation Begin the cooling process A.Remove all clothing B.Volume resuscitate to allow for sweating C.Cool the skin with ice bath.

Agitated Delirium (Life-threats) Hyperthermia Volume depletion Rhabdomyolysis Seizures

CNS Agitation Increased Neuronal Firing Reuptake Blockade Exaggerated Sympathetic Response Model for Cocaine Toxicity Seizures Hyperthermia Cardiovascular complications

Control the Situation Struggling increases catecholamine release which can exacerbate cocaine toxicity Prolonged struggling or chasing increases heat production Hyperthermia is one of the best prognosticators for lethal cocaine events

Agitated Delirium (Treatment) Rapid Cooling Volume resuscitation Sedation

Control the Situation Give good general care for seriously ill patients A. IV dextrose and thiamine B. Avoid naloxone C. Oxygen and cardiac monitor

Control the Situation Stop the heat production – use chemical sedation A. Benzodiazepines are preferred B. Barbiturates are a good second choice C. Avoid all antipsychotics

Agitated Delirium (Treatment) Choice of Sedatives 1.IV always preferred2.If IM is requiredMidazolamLorazepam DiazepamSodium Amytal Barbiturates

Consequential Complications BenzodiazepinesButyrophenones Sedation  excessive  Prolonged  Respiratory depression Delay to sedation  extrapyramidal reactions (dystonia)  torsades de pointes  thermoregulatory disorders  neuroleptic malignant syndrome

Six Good Reasons to Avoid Phenothiazines and Butyrophenones Lower seizure threshold Interfere with heal dissipation Exacerbate tachycardia Produce hypotension Increase heat production (movement disorders) Not cross-tolerant with ethanol and other sedative hypnotics

Ability of Propranolol to Modify Cocaine Toxicity DrugBPPulsepHTempSeizuresDeath Cocaine  PropranololNN      Catravas et al: J Pharm Exp Ther 217:315,1961. Guinn et al: Clin Tox 16:499,1980.

Agitated Delirium (Pitfalls) Use of Beta adrenergic antagonists Use of Mixed Alpha-Beta adrenergic antagonists Failure to Aggressively Cool Use of Dantrolene