Case #1 Toxin and Discussion

CLINICAL COURSE

The patient now admits to swallowing several "dime bags" of cocaine approximately 3 hours prior to presentation when the police raided his house.

QUESTIONS AND CONTROVERSIAL ISSUES

I) Describe the difference between a "Body packer" and "Body stuffer"

A) Body packers are drug smugglers who ingest illegal contraband methodically wrapped in multilayered condoms or latex in order to deliver the goods across international borders once safely through customs.

B) Body stuffers are those individuals who suddenly "swallow the evidence" during drug raids in carelessly wrapped single layered baggies, aluminum foil, or ziplock bags when about to be incarcerated by the authorities. Due to the faulty wrapping technique, despite less purity of the drug ingested, body stuffers are often more vulnerable to life-threatening toxicities secondary to leakage.

II) How should this patient's cocaine-associated chest pain and hypertension be treated?

1. Benzodiazepines- First line therapy (in high doses)
2. Nitroglycerin- for control of ischemic pain and HTN
3. Labetalol- alpha/beta blocker (the use of propranolol will leave the alpha portion unopposed theoretically exacerbating cocaine's toxicity).
4. Nitroprusside- for refractory HTN
5. Calcium channel blockers- controversial.

III) What would be the best mode of gastric decontamination in this setting?

1. Syrup of ipecac- contraindicated, patient unstable and potential for cocaine-induced seizure activity.
2. Gastric lavage- not very efficacious (3 hours post ingestion); low return of cocaine packets due to size of lavage tube; may rupture bags in process.
3. Activated charcoal- may adsorb leaking cocaine in gut
4. Whole bowel irrigation- (PEG solution) 1-2L/hr Rapid, efficacious, osmotically/electrolyte-safe. Clearly the choice for decontamination in this patient.

IV) Is there a role for thrombolytics in patient's with cocaine induced myocardial ischemia?

• Mechanisms of cocaine-induced myocardial ischemia
  1. Coronary vasospasm
  2. Accelerated atherogenesis
  3. Thrombotic plaque formation
• Consider thrombolytics if strict ECG criteria are met. However, this younger patient population will often demonstrate false positive ECG readings due to "early repolarization" and ventricular hypertrophy.
• Cocaine patients are prone to intracranial bleeds, therefore, liberal use of thrombolytics is discouraged. In small case series, however, the thrombolytic complication rate is low.
• At present, the use of thrombolytics in these patients remains controversial.

V) What consultations should be requested?

• Cardiology- Unstable patient with acute anterior wall MI; consideration of thrombolytics.
• Surgery- Patient ingested potentially lethal dose of cocaine packets, consult for emergent exploratory laparotomy to remove the source of toxicity.
• Toxicology service or Poison Control Center
• Radiology- Abdominal CAT scan or contrast studies

VI) Should all patients with cocaine-induced chest pain be admitted?

• Overall mortality rate from cocaine-associated chest pain is low
• Not all chest pain in cocaine abusers is cardiac-related (eg- PTX, pneumomediastinum, septic emboli)
• Some authors recommend admitting all patients with cocaine induced chest pain to a monitored setting to R/O myocardial ischemia
• Others are less conservative and send the majority of these patients home after a brief observation period.
• Compromise- maintain a high index of suspicion, take a detailed cardiac history (respecting cocaine abuse as a legitimate cardiac risk factor), monitor the patient, and carefully interpret the ECG.
• Patients with a known ingestion of packets of cocaine should be admitted and undergo gastric decontamination.

CLINICAL COURSE

The patient's chest pain and hypertension eventually resolves with large doses of nitroglycerin and benzodiazepines. The patient is administered activated charcoal and polyethylene glycol solution by the ED physician. Because of the ST segment elevations, the cardiologist elects to give thrombolytics. However, since thrombolytics were "on board" the general surgeon refuses to take the patient to the OR for exploratory laparotomy and removal of the cocaine packets. The patient is transferred to the ICU, where he eventually recovers and is discharged with a 10% ejection fraction.