1. 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

2. 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

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

4. 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

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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

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

19. 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

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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

31. 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