Rosen & Barkin's 5-Minute Emergency Medicine Consult (163 page)

FOLLOW-UP

• Clinically significant bleeding
  
• Utilization of reversal agents
  

• Insignificant bleeding that is controlled without the use of anticoagulant reversal
  
• Discussion with outpatient hematologist or primary care physician (PCP) is ideal for follow-up
  

• Blood bank reversal medication availability
  
• Surgical/Interventional Radiology specialty availability to control hemorrhage
  

Close follow-up and monitoring is paramount

• Prophylactic heparin dosing does not typically confer an increased risk of major bleeding
  
• LMWH is not always reversed with protamine—it is compound specific
  
• If >12 hr have elapsed since LMWH administration, protamine may not be necessary
  
• Single-dose aspirin suppresses COX1 for 1 wk
  
• Caution is needed with renal impairment if utilizing FXa inhibitors, dabigatran, or hirudin derivatives
  
• FFP as 1st-line replacement has to be weighed against extensive volume expansion
  

• Ageno W, Gallus AS, Wittkowsky A, et al. Oral anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis.
  Chest.
  2012;141:e44S–e88S.
  
• Tawil I, Seder D, Duprey J. Emergency management of coagulopathy in acute intracranial hemorrhage. EB Medicine.
  EM Crit Car.
  2012;2:2.
  
• van Ryn J, Stangier J, Haertter S, et al. Dabigatran etexilate—a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity.
  Thromb Haemost
  . 2010;103:1116–1127.
  

CODES

• 286.6 Defibrination syndrome
  
• 286.9 Other and unspecified coagulation defects
  
• V58.61 Long-term (current) use of anticoagulants
  

BASICS

• Sympathomimetic
  
• Inhibits neurotransmitter reuptake at the nerve terminal
  
• Metabolism:
  
  • Hepatic degradation
    
  • Nonenzymatic hydrolysis
    
  • Cholinesterase metabolism
    

• IV, nasal, oral administration of cocaine
  
• Oral ingestion:
  
  • Body stuffers:
    
    • Ingest hastily wrapped packets in attempt to evade police.
      
  • Body packers:
    
    • Ingest cocaine packets to smuggle the drug using couriers’ oral, rectal, and vaginal cavities.
      
    • Cocaine is wrapped carefully in packets containing large amounts of drug.
      

DIAGNOSIS

• Sympathomimetic toxidrome
  
• Cardiovascular:
  
  • HTN
    
  • Tachycardia
    
  • Chest pain (angina)
    
• Respiratory:
  
  • Tachypnea
    
  • Pleuritic chest pain:
    
    • Pneumomediastinum
      
    • Pneumothorax
      
    • Bronchitis
      
    • Pulmonary infarction
      
  • Cough
    
• CNS:
  
  • Agitation
    
  • Tremulousness
    
  • Coma
    
  • Seizures
    
  • Stroke
    
• Miscellaneous:
  
  • Hyperthermia (poor prognosis)
    
  • Limb ischemia (inadvertent intra-arterial injection)
    
  • Corneal ulcerations (heavy crack smokers):
    
    • Owing to local chemical and thermal irritation that disrupts corneal epithelium
      
  • Rhabdomyolysis
    

For body packers and stuffers:

• Time since ingestion
  
• Route of ingestion (oral, rectal, vaginal)
  
• Number of packets ingested
  
• Material and method of packing
  

Sympathomimetic toxidrome:

• HTN
  
• Tachycardia
  
• Tachypnea
  
• Hyperthermia
  
• Diaphoresis
  
• Mydriasis
  
• Neuromuscular hyperactivity
  

• Recognition of the sympathomimetic toxidrome caused by cocaine:
  
  • Distinguish from anticholinergic toxidrome.
    
• Toxidrome recognition:
  
  • Sympathomimetic:
    
    • Heart rate (tachycardia)
      
    • BP (increased)
      
    • Moist skin
      
    • Bowel sounds present
      
    • Temperature (increased)
      
    • No urinary retention
      
  • Anticholinergic:
    
    • Heart rate (tachycardia)
      
    • BP (increased)
      
    • Dry skin
      
    • Bowel sounds diminished
      
    • Temperature (increased)
      
    • Urinary retention present
      

• CBC
  
• Electrolytes, BUN, creatinine, glucose
  
• Urinalysis dip for myoglobin
  
• Cardiac enzymes (troponin, creatine phosphokinase [CPK]) for:
  
  • Anginal chest pain
    
  • Abnormal results on ECG
    
• CPK for evidence of myoglobinuria
  
• Toxicology screen
  

• ECG:
  
  • For anginal chest pain
    
  • Consider possibility of myocardial infarction with cocaine-related chest pain.
    
• CXR:
  
  • For chest pain or shortness of breath
    
  • Check for pneumomediastinum, pneumothorax, aortic rupture.
    
• Abdominal radiograph:
  
  • For body packers/stuffers
    
  • Usually produces negative result for stuffers because drug is loosely packed in cellophane
    
  • Positive for packers because drug is densely packed and usually radiopaque
    
• CT of the abdomen with contrast:
  
  • When unreliable history of body packers/stuffers and nothing visualized on abdominal frontal radiograph
    
• CT brain scan:
  
  • For altered mental status or severe headache
    
  • Detects cerebral ischemia or hemorrhage
    

Other agents with sympathomimetic effects

• Theophylline
  
• Caffeine
  
• Amphetamines
  
• Albuterol
  
• Tricyclic antidepressants
  
• Antihistamines
  
• Phencyclidine (PCP)
  
• Thyrotoxicosis
  
• Neuroleptic malignant syndrome
  
• Hallucinogens
  

TREATMENT

• Establish IV access
  
• Cardiac monitor:
  
  • Chest pain may be ischemic.
    
  • Benzodiazepine therapy to control agitation
    
• When drug is used as a “speedball” (combination of heroin and cocaine), administer naloxone in increments to reverse coma.
  

• ABCs
  
• Establish IV access.
  
• Establish cardiac monitor.
  
• Provide therapy with naloxone (Narcan), thiamine, dextrose (or Accu-Check) for altered mental status
  

• Supportive care for mildly symptomatic patients
  
• Benzodiazepines:
  
  • For agitation and tremor
    
  • Initial agents for hypertension and tachycardia
    
• Cooling measures for hyperthermia:
  
  • Evaporative–convective method
    
• Treat rhabdomyolysis:
  
  • Hydrate with 0.9% NS
    
  • Alkalinization with IV bicarbonate in severe cases
    
• Cardiac chest pain:
  
  • Aspirin
    
  • Nitrates
    
  • Oxygen
    
  • Opiates
    
  • Avoid β-blockers because of unopposed α-stimulation
    
  • Angiography/angioplasty/thrombolysis for acute myocardial infarction
    
• HTN/tachycardia:
  
  • Benzodiazepine initial agent
    
  • Use α-blocking agent (phentolamine) as sole agent or combine with β-blocker (propranolol, esmolol) if unresponsive to benzodiazepine.
    
  • Use labetalol cautiously (does not have equal α- and β-blocking properties).
    
  • IV nitroglycerin/nitroprusside for severe unresponsive hypertension
    
• Body packer/stuffers:
  
  • Treat asymptomatic or minimally symptomatic body packers and body stuffers:
    
    • Single-dose activated charcoal is appropriate for asymptomatic or minimally symptomatic body stuffers
      
    • Whole-bowel irrigation with polyethylene glycol electrolyte lavage solution (efficacy unknown)
      
  • Consult with surgeons for symptomatic body packers and stuffers.
    
    • If toxicity is not easily managed with previously suggested pharmacologic therapy, remove the drug packets intraoperatively.