Corey M. Slovis

Cocaine-Related Medical Problems: Consecutive Series of 233 Patients

PURPOSEnLittle information describing common cocaine-related medical problems is available. This study examined the nature, frequency, treatment, incidence of complications, and emergency department deaths of patients seeking medical care for acute and chronic cocaine-associated medical problems.nnnPATIENTS AND METHODSnA consecutive series of 233 hospital visits by 216 cocaine-using patients over a 6-month period during 1986 and 1987 was studied. Medical records were retrospectively reviewed to determine patient characteristics, nature of complications, treatment, and outcome.nnnRESULTSnPatients most commonly used cocaine intravenously (49%), but freebase or crack use was also common (23.3%). Concomitant abuse of other intoxicants, especially alcohol, was frequently seen (48.5%). The vast majority of complaints were cardiopulmonary (56.2%), neurologic (39.1%), and psychiatric (35.8%); multiple symptoms were often present (57.5%). The most common complaint was chest pain though rarely was it believed to represent ischemia. Altered mental status was common (27.4%) and ranged from psychosis to coma. Short-term pharmacologic intervention was necessary in only 24% of patients, and only 9.9% of patients were admitted. Acute mortality was less than 1%.nnnCONCLUSIONnMost medical complications of cocaine are short-lived and appear to be related to cocaines hyperadrenergic effects. Patients usually do not require short-term therapy or hospital admission. Acute morbidity and mortality rates from cocaine use in patients presenting to the hospital are very low, suggesting that a major focus in the treatment of cocaine-related emergencies should be referral for drug abuse detoxification and treatment.

The syndrome of alcoholic ketoacidosis.

PURPOSEnTo further elucidate the clinical spectrum of alcoholic ketoacidosis (AKA).nnnPATIENTS AND METHODSnA case series of 74 patients with AKA defined as a wide anion gap metabolic acidosis unexplained by any other disorder or toxin, including any patient with a history of chronic alcohol abuse. The setting was the Medical Emergency Department at Grady Memorial Hospital in Atlanta, Georgia, a university-affiliated inner-city hospital.nnnRESULTSnAKA is a common disorder in the emergency department, more common than previously thought. The acid-base abnormalities are more diverse than just a wide-gap metabolic acidosis and often include a concomitant metabolic alkalosis, hyperchloremic acidosis, or respiratory alkalosis. Lactic acidosis is also common. Semiquantitative serum acetoacetate levels were positive in 96% of patients. Elevated blood alcohol levels were present in two thirds of patients in whom alcohol levels were determined, and levels consistent with intoxication were seen in 40% of these patients. Electrolyte disorders including hyponatremia, hypokalemia, hypophosphatemia, hyperglycemia, hypocalcemia, and hypomagnesemia were common on presentation. The most common symptoms were nausea, vomiting, and abdominal pain. The most common physical findings were tachycardia, tachypnea, and abdominal tenderness. Altered mental status, fever, hypothermia, or other abnormal findings were uncommon and reflected other underlying processes.nnnCONCLUSIONSnAKA is a common disorder in chronic malnourished alcoholic persons. The acid-base abnormalities reflect not only the ketoacidosis, but also associated extracellular fluid volume depletion, alcohol withdrawal, pain, sepsis, or severe liver disease. Although the pathophysiology is complex, the syndrome is rapidly reversible and has a low mortality.

A toxicity study of parenteral thiamine hydrochloride

Thiamine deficiency is not uncommon in certain populations and clinical disease states such as Wernickes encephalopathy or beriberi. Rapid parenteral repletion may be required, yet questions about the safety of IV thiamine have been raised because of reports of anaphylaxis. Our study was a prospective evaluation of the safety of thiamine hydrochloride given as a 100-mg IV bolus in 989 consecutive patients (1,070 doses). A total of 12 adverse reactions (1.1%) were reported. Minor reactions consisting of transient local irritation were seen in 11 patients (1.02%), and there was only one major reaction (0.093%) consisting of generalized pruritus. Thiamine hydrochloride may be administered intravenously without undue concern. Intradermal test doses before administration are not warranted unless patients have had previous allergic reactions.

Experience with esmolol for the treatment of cocaine-associated cardiovascular complications

The authors report their experience using esmolol, an ultra-short acting beta-adrenergic antagonist, for the treatment of seven patients with cocaine-associated cardiovascular complications. No consistent hemodynamic benefit was found with the use of this drug. Although there was a decline in mean heart rate of 23% (range 0% to 35%), they were unable to show a consistent antihypertensive response. Adverse effects occurred in three patients. This included one patient with a marked exacerbation of hypertension and one who became hypotensive. Another patient developed emesis and lethargy during esmolol therapy and required endotracheal intubation. They do not recommend the routine use of esmolol for cocaine cardiotoxicity.

Success rates for initiation of intravenous therapy en route by prehospital care providers.

The optimal extent of prehospital care, including intravenous (IV) therapy for critically ill patients, remains unclear. The authors evaluated the success rate for IV cannulation in a moving ambulance by trained emergency medical technicians and paramedics in 641 adult medical- and trauma-related cases. At least one IV line was started in 80% of medical patients and 92% of trauma patients, regardless of blood pressure. In hypotensive patients, the success rates for at least one IV in medical and trauma patients were 80% and 95%, respectively. These data suggest that IV lines can be secured with a high degree of success en route to the hospital by trained personnel, and that prompt transport of unstable patients should not be delayed solely to obtain IV access.

Diabetic ketoacidosis and infection: Leukocyte count and differential as early predictors of serious infection

The records of 153 patients who presented to an emergency department with diabetic ketoacidosis were reviewed to determine whether any admission evaluation laboratory data could serve as a predictor of occult or coexisting infection. Ten patients with admission radiographs already demonstrating active infection (pneumonia or tuberculosis) and two patients with wet gangrene of an extremity were not included in subsequent statistical analysis, as their infections were diagnosed on initial evaluation. Analysis of readily available admission variables revealed that when age, sex, temperature, glucose, serum bicarbonate, pH, total leukocyte count, and differential are subjected to univariate and multivariate discriminant analysis, only an elevation in band neutrophils reliably predicted infection. Approximately half of our patients with elevated band counts (10 or greater) had a coexisting occult infection. An elevated band count was predictive of an occult coexisting major infection with a sensitivity of 100% (19/19) and a specificity of 80% (98/122).

Predicting the severity of cocaine-associated rhabdomyolysis

STUDY OBJECTIVESnThe syndrome of rhabdomyolysis associated with cocaine use has been recently described, but the incidence, severity, risk factors, and complications are unknown. This study sought to describe the spectrum of the syndrome and identify clinical features of patients at risk.nnnDESIGNnRetrospective case series with analysis of common clinical features.nnnSETTINGnMedical emergency department of an urban teaching hospital serving an indigent population.nnnTYPES OF PARTICIPANTSnED patients with acute cocaine intoxication and a serum creatine kinase (all MM) of more than 500 U/L (8.3 ukat/L) who were admitted for in-hospital management.nnnMEASUREMENTS AND MAIN RESULTSnTwenty-nine patients, representing 5% of cocaine-related patient visits, were identified over 20 months. Patients were divided into three groups: mild, characterized by anxiety, tachycardia, diaphoresis, dyspnea, or chest pain; moderate, characterized by delirium, agitation, fever, leukocytosis, or an elevated serum creatinine; and severe, characterized by seizure, coma, hypotension, arrhythmia, or cardiac arrest. There was a significant association between the rating system for level of intoxication and the severity of rhabdomyolysis and its complications (P less than .01). Patients at highest risk for complications of rhabdomyolysis were those in the moderate or severe groups.nnnCONCLUSIONnThis classification system may be useful for the management of patients with acute cocaine intoxication, predicting those patients in whom aggressive therapy should be initiated in the ED to minimize the complications of rhabdomyolysis.

Severe alcohol intoxication: A study of 204 consecutive patients

We report a five month retrospective analysis of 204 consecutive patients seen in an adult medical emergency department with blood alcohol concentrations (BAC) in excess of 400 mg/dl. The average BAC was 467 mg/dl with a range of 400-719 mg/dl. In 153 patients (75%) the BAC was 400-500 mg/dl, in 47 patients (23%) the BAC was 500-600 mg/dl and in 4 patients (2%) the BAC was greater than 600 mg/dl. Eighty-eight percent of the patients were oriented to person, place, and time upon questioning, 12% were disoriented or unresponsive to noxious stimuli. None of the four patients whose BAC was greater than 600 mg/dl were initially alert and oriented and only eight of the unresponsive patients had a BAC below 500 mg/dl (p less than .001). Sixteen patients (8%) were admitted. Three of the admissions were for continued unresponsiveness presumed due to ethanol, the other thirteen were for coexistent medical conditions. There were no significant associations between BAC and vital sign abnormalities.

Profound alkalemia during treatment of tricyclic antidepressant overdose: A potential Hazard of combined hyperventilation and intravenous bicarbonate

Two patients with cardiovascular and neurologic toxicity from intentional tricyclic antidepressant overdose received bicarbonate infusions in association with hyperventilation for alkalinization. Both patients developed profound alkalemia. One patient died, and the other patients alkalemia resolved prior to her death. Bicarbonate infusions have become the standard of care for symptomatic tricyclic antidepressant toxicity. Severe alkalemia (pH greater than 7.60) in other settings has been reported to correlate with higher rates of mortality. Careful monitoring of the pH is imperative when bicarbonate therapy is used. It is probably prudent to keep the pH level in the range 7.45 to 7.60. Capnography may also be useful in monitoring patients during alkalinization.

Survival in a heat stroke victim with a core temperature in excess of 46.5 C

Presented is a case report of a 52-year-old male heat stroke victim. The patient presented in deep coma with a temperature above 42 C. Following rapid assessment, the patient was intubated, rehydration was begun, and he was externally cooled with ice bags and internally cooled with ice water gastric lavage. After 25 minutes the patients core temperature was measured at 46.5 C (115.7 F). Multiple organ system failure developed over the ensuing days. With aggressive care, the patient improved dramatically and was discharged at prior baseline status on the 24th day of hospitalization. This case now represents the highest human body temperature elevation reported without permanent residua.