Cocaine

Track D

September 17, 2003

Barcelona

Lewis R. Goldfrank, MDProfessor and Chairman of Emergency Medicine

New York University Medical Center Bellevue Hospital Center

New York University School of MedicineMedical 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, a2 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

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 preferred 2. If IM is required

Midazolam Midazolam

Lorazepam Lorazepam

Diazepam Sodium Amytal

Barbiturates

Consequential Complications

Benzodiazepines Butyrophenones

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

Drug BP Pulse pH Temp Seizures Death

Cocaine

Propranolol N N

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