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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Lutfallah SC, Brown E, Spillers NJ, Tandon A, Kelkar RA, Ahmadzadeh S, Viswanath O, Varrassi G, Shekoohi S, Kaye AD. Topical Cocaine Hydrochloride Nasal Solution: Anesthetic and Surgical Considerations. Cureus 2023; 15:e42804. [PMID: 37664274 PMCID: PMC10470476 DOI: 10.7759/cureus.42804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Adequate surgical view during various types of nasal procedures is essential for surgical operations to be performed in a safe, efficient, and successful manner. Minimizing bleeding during surgery is an important way of increasing visualization that is commonly achieved by using a vasoconstrictive agent to control intraoperative hemorrhage. Many otolaryngologists choose to employ topical cocaine to minimize bleeding during surgery owing to its vasoconstrictive properties, while simultaneously benefitting from its dual local anesthetic effects. The relative benefit of topical cocaine for otolaryngologic procedures when compared to other topical analgesics and vasoconstrictors remains a topic of discussion due to the multiple potential cardiac and central nervous system side effects associated with cocaine administration. Furthermore, there is not a scientifically backed maximal safe dose published; instead, most of the guidelines for intranasal cocaine use are based on untested clinical practice. Despite this, the short latency, adequate duration of action, and inherent vasoconstrictive and decongestive capabilities make cocaine a valuable anesthetic agent for use in clinical procedures. As the relative benefit of using topical cocaine compared to the use of other vasoconstrictors and analgesics for nasal procedures remains undetermined in the current literature, this leaves the need for a comprehensive review of research that explores the risks and benefits of using topical cocaine in nasal procedures based on clinical trials that compare intranasal cocaine with various other analgesics and vasoconstrictors.
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Affiliation(s)
- Salim C Lutfallah
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, USA
| | - Elise Brown
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Noah J Spillers
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Anamika Tandon
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, USA
| | - Rucha A Kelkar
- School of Medicine, Medical University of South Carolina, Charleston, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Omar Viswanath
- Pain Management, Valley Pain Consultants - Envision Physician Services, Phoenix, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Lin AL, Nah G, Tang JJ, Vittinghoff E, Dewland TA, Marcus GM. Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation. Eur Heart J 2022; 43:4933-4942. [PMID: 36257330 DOI: 10.1093/eurheartj/ehac558] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/18/2022] [Accepted: 09/26/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is now regarded as a preventable disease, requiring a search for modifiable risk factors. With legalization of cannabis and more lenient laws regarding the use of other illicit substances, investigation into the potential effects of methamphetamine, cocaine, opiate, and cannabis exposure on incident AF is needed. METHODS AND RESULTS Using Office of Statewide Health Planning and Development databases, a longitudinal analysis was performed of adult Californians ≥18 years of age who received care in an emergency department, outpatient surgery facility, or hospital from 1 January 2005 to 31 December 2015. Associations between healthcare coding for the use of each substance and a new AF diagnosis were assessed. Among 23,561,884 patients, 98 271 used methamphetamine, 48 701 used cocaine, 10 032 used opiates, and 132 834 used cannabis. Of the total population, 998 747 patients (4.2%) developed incident AF during the study period. After adjusting for potential confounders and mediators, use of methamphetamines, cocaine, opiates, and cannabis was each associated with increased incidence of AF: hazard ratios 1.86 [95% confidence interval (CI) 1.81-1.92], 1.61 (95% CI 1.55-1.68), 1.74 (95% CI 1.62-1.87), and 1.35 (95% CI 1.30-1.40), respectively. Negative control analyses in the same cohort failed to reveal similarly consistent positive relationships. CONCLUSION Methamphetamine, cocaine, opiate, and cannabis uses were each associated with increased risk of developing incident AF. Efforts to mitigate the use of these substances may represent a novel approach to AF prevention.
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Affiliation(s)
- Anthony L Lin
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Gregory Nah
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Janet J Tang
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Thomas A Dewland
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Gregory M Marcus
- Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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Lucyk SN. Acute Cardiovascular Toxicity of Cocaine. Can J Cardiol 2022; 38:1384-1394. [PMID: 35697321 DOI: 10.1016/j.cjca.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/22/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022] Open
Abstract
Cocaine is one of the most commonly abused drugs and represents a major public health concern. Cocaine users frequently present to the emergency department, with chest pain being the most common presenting complaint. The incidence of acute myocardial infarction in patients with cocaine-associated chest pain is often quoted as 6%, but it is highly variable depending on the included population. Risk assessment can be challenging in these patients; serial assessment of electrocardiograms and troponins is often required. This review focuses on the assessment and management of patients presenting with cocaine-associated chest pain and cardiotoxicity. Specific treatments are discussed, including benzodiazepines, nitroglycerin, calcium channel blockers, and phentolamine, and how treatment priorities differ from patients with noncocaine presentations. The use of beta-blockers in this population remains controversial, and the literature around its use is reviewed. The most recent literature and recommendations for the use of percutaneous coronary intervention and fibrinolytics in cocaine-associated myocardial infarction is discussed as well. Cocaine-associated dysrhythmias are suggested to be the cause of sudden cardiac death in some users. The pathophysiology and evidence-based treatments for dysrhythmias are reviewed. This review provides evidence-based recommendations for the assessment and management of patients presenting with cocaine-associated cardiovascular toxicity.
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Affiliation(s)
- Scott N Lucyk
- Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, Alberta, Canada.
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Chang CY, Wu PH, Hsiao CT, Chang CP, Chen YC, Wu KH. Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis. Resuscitation 2021; 162:188-197. [PMID: 33662526 DOI: 10.1016/j.resuscitation.2021.02.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/23/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system. RESULTS We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the "before 2010" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the "after 2010" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low. CONCLUSIONS This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations. TRIAL REGISTRATION The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).
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Affiliation(s)
- Chih-Yao Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Po-Han Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan.
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A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2018; 6:146-148. [PMID: 30294672 DOI: 10.12691/ajmcr-6-7-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cocaine is a commonly abused illicit drug in the United States. The complex effects of cocaine on the conduction system of the human heart has not been completely understood. Cocaine acts as a sympathomimetic by inhibition of reuptake of neuronal catecholamines, leading mostly to tachyarrhythmias on presentation. However, cocaine also exerts other effects on the conduction system including sympathomimetic, sino-bradycardic as well as local anesthetic properties. While Multiple cases of atrioventricular (AV) conduction blocks including first degree AV block, Mobitz type I and third degree AV blocks have been previously reported, we hereby present the first case report of cocaine- induced Mobitz type II second degree AV block. This case occurred in a 55 year old woman who presented with retrosternal chest pressure and tested positive for cocaine abuse as documented by urine toxicology test. Patient spontaneously converted to normal sinus rhythm the following day post admission to the hospital. Cocaine is known to inhibit sodium channels and thus has been known to decrease SA node automaticity and conduction via AV node. Electrophysiology studies have previously confirmed cocaine mediated delay in impulse conduction and repolarization. Though rare, physicians should be aware of the possibility of bradyarrhythmias associated with cocaine abuse in order to apply standard therapy such as pacemaker in the event of non-resolution of this serious arrhythmia.
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Abstract
Sodium bicarbonate is a well-known antidote for tricyclic antidepressant (TCA) poisoning. It has been used for over half a century to treat toxin-induced sodium channel blockade as evidenced by QRS widening on the electrocardiogram (ECG). The purpose of this review is to describe the literature regarding electrophysiological mechanisms and clinical use of this antidote after poisoning by tricyclic antidepressants and other agents. This article will also address the literature supporting an increased serum sodium concentration, alkalemia, or the combination of both as the responsible mechanism(s) for sodium bicarbonate's antidotal properties. While sodium bicarbonate has been used as a treatment for cardiac sodium channel blockade for multiple other agents including citalopram, cocaine, flecainide, diphenhydramine, propoxyphene, and lamotrigine, it has uncertain efficacy with bupropion, propranolol, and taxine-containing plants.
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Lipton JW, Mangan KP, Silvestri JM. Acute Cocaine Toxicity: Pharmacology and Clinical Presentations in Adult and Pediatric Populations. J Pharm Pract 2016. [DOI: 10.1177/089719000001300207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cocaine remains the most prevalent drug responsible for emergency department (ED) visits. A majority of acute cocaine toxicity cases involve young, habitual, adult cocaine users and often present with a range of cardiac, neurologic, gastrointestinal (GI) or renal symptoms. In addition, atypical populations (neonates, infants, toddlers, young children and adolescents) are presenting in EDs with varying symptoms that are unknowingly associated with cocaine exposure. Unfortunately, juvenile presentations are generally anecdotal in nature, and while enlightening, are difficult to quantify epidemiologically. Outlining the types of symptom presentation in these young populations may assist healthcare providers in expediting proper treatment for such demographic groups. Therefore, this review examines the current knowledge regarding cocaine's pharmacologic activity as it relates to its potential toxicity, and outlines the clinical manifestations of cocaine exposure and toxicity in adult and pediatric populations. We conclude from the available clinical reports that there must be a higher index of suspicion in the pediatric population to identify exposed infants and children. Improved recognition and identification in both typical and atypical populations will result in better characterization of acute cocaine toxicity.
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Affiliation(s)
- Jack W. Lipton
- Departments of Pediatrics and Pharmacology, Rush University and Rush Chaldren's Hospital, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL 60612
| | - Kile P. Mangan
- Departments of Pediatrics and Pharmacology, Rush University and Rush Chaldren's Hospital, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL 60612
| | - Jean M. Silvestri
- Department of Pediatrics, Rush University and Rush Chaldren's Hospital, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL 60612
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Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, Olson KR, Ramoska EA, Lange RA. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila) 2016; 54:345-64. [PMID: 26919414 DOI: 10.3109/15563650.2016.1142090] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death. OBJECTIVE The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse. METHODS MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and β/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of β-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined β/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine. CONCLUSIONS High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.
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Affiliation(s)
- John R Richards
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Dariush Garber
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Erik G Laurin
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Timothy E Albertson
- b Department of Internal Medicine, Divisions of Toxicology, Pulmonary and Critical Care , University of California Davis Medical Center , Sacramento , CA , USA
| | - Robert W Derlet
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Ezra A Amsterdam
- c Department of Internal Medicine, Division of Cardiology , University of California Davis Medical Center , Sacramento , CA , USA
| | - Kent R Olson
- d Departments of Medicine and Clinical Pharmacy , University of California, San Francisco, Medical Director, California Poison Control System, San Francisco Division , San Francisco , CA , USA
| | - Edward A Ramoska
- e Department of Emergency Medicine , Drexel University , Philadelphia , PA , USA
| | - Richard A Lange
- f Department of Internal Medicine, Division of Cardiology , Texas Tech University Health Sciences Center , El Paso , TX , USA
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Sharma J, Rathnayaka N, Green C, Moeller FG, Schmitz JM, Shoham D, Dougherty AH. Bradycardia as a Marker of Chronic Cocaine Use: A Novel Cardiovascular Finding. Behav Med 2016; 42:1-8. [PMID: 24621090 PMCID: PMC4162850 DOI: 10.1080/08964289.2014.897931] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Few studies have examined the effects of chronic cocaine use on the resting surface electrocardiogram (ECG) between exposures to cocaine. Researchers compared 12-lead ECGs from 97 treatment-seeking cocaine-dependent patients, with ECG parameters from 8,513 non-cocaine-using control patients from the Atherosclerosis Risk in Communities study. After matching and adjusting for relevant covariates, cocaine use demonstrated large and statistically reliable effects on early repolarization, bradycardia, severe bradycardia, and heart rate. Current cocaine dependence corresponds to an increased odds of demonstrating early repolarization by a factor of 4.92 and increased odds of bradycardia and severe bradycardia by factors 3.02 and 5.11, respectively. This study demonstrates the novel finding that long-lasting effects of cocaine use on both the cardiac conduction and the autonomic nervous system pose a risk of adverse cardiovascular events between episodes of cocaine use, and that bradycardia is a marker of chronic cocaine use.
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Affiliation(s)
| | - Nuvan Rathnayaka
- Department of Psychiatry, Center for Neurobehavioral Research on Addictions, University of Texas Health Science Center at Houston
| | - Charles Green
- Department of Psychiatry, Center for Neurobehavioral Research on Addictions, University of Texas Health Science Center at Houston
| | - F. Gerard Moeller
- Department of Psychiatry, VCU Institute on Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine
| | - Joy M. Schmitz
- Department of Psychiatry, Center for Neurobehavioral Research on Addictions, University of Texas Health Science Center at Houston
| | | | - Anne Hamilton Dougherty
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston
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Cardiovascular and Hepatic Toxicity of Cocaine: Potential Beneficial Effects of Modulators of Oxidative Stress. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2015; 2016:8408479. [PMID: 26823954 PMCID: PMC4707355 DOI: 10.1155/2016/8408479] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/19/2015] [Accepted: 11/01/2015] [Indexed: 12/20/2022]
Abstract
Oxidative stress (OS) is thought to play an important role in the pharmacological and toxic effects of various drugs of abuse. Herein we review the literature on the mechanisms responsible for the cardiovascular and hepatic toxicity of cocaine with special focus on OS-related mechanisms. We also review the preclinical and clinical literature concerning the putative therapeutic effects of OS modulators (such as N-acetylcysteine, superoxide dismutase mimetics, nitroxides and nitrones, NADPH oxidase inhibitors, xanthine oxidase inhibitors, and mitochondriotropic antioxidants) for the treatment of cocaine toxicity. We conclude that available OS modulators do not appear to have clinical efficacy.
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Stankowski RV, Kloner RA, Rezkalla SH. Cardiovascular consequences of cocaine use. Trends Cardiovasc Med 2015; 25:517-26. [DOI: 10.1016/j.tcm.2014.12.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 11/28/2022]
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Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California. Am J Cardiovasc Drugs 2015; 15:43-50. [PMID: 25567789 DOI: 10.1007/s40256-014-0104-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented. OBJECTIVE The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes. METHODS We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP). RESULTS Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs. CONCLUSIONS Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.
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Kozor R, Grieve SM, Buchholz S, Kaye S, Darke S, Bhindi R, Figtree GA. Regular cocaine use is associated with increased systolic blood pressure, aortic stiffness and left ventricular mass in young otherwise healthy individuals. PLoS One 2014; 9:e89710. [PMID: 24717541 PMCID: PMC3981670 DOI: 10.1371/journal.pone.0089710] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 01/22/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The cardiovascular impact of cocaine use in otherwise healthy individuals who consider themselves 'social' users is not well established. METHODS/RESULTS Twenty regular cocaine users and 20 control subjects were recruited by word-of-mouth. Cardiovascular magnetic resonance was performed to assess cardiac and vascular structure and function. Cocaine users had higher systolic blood pressure compared to non-users (134±11 vs 126±11 mmHg, p = 0.036), a finding independent of age, body surface area, smoking and alcohol consumption. Cocaine use was associated with increased arterial stiffness - reflected by reduced aortic compliance (1.3±0.2 vs 1.7±0.5 cm2×10-2.mmHg-1, p = 0.004), decreased distensibility (3.8±0.9 vs 5.1±1.4 mmHg-1.10-3, p = 0.001), increased stiffness index (2.6±0.6 vs 2.1±0.6, p = 0.005), and higher pulse wave velocity (5.1±0.6 vs 4.4±0.6 m.s-1, p = 0.001). This change in aortic stiffness was independent of vessel wall thickness. Left ventricular mass was 18% higher in cocaine users (124±25 vs 105±16 g, p = 0.01), a finding that was independent of body surface area, and left atrial diameter was larger in the user group than controls (3.8±0.6 vs 3.5±0.3 cm, p = 0.04). The increased left ventricular mass, systolic blood pressure and vascular stiffness measures were all associated with duration and/or frequency of cocaine use. No late gadolinium enhancement or segmental wall motion abnormalities were seen in any of the subjects. CONCLUSIONS Compared with the non-user control cohort, cocaine users had increased aortic stiffness and systolic blood pressure, associated with greater left ventricular mass. These measures are all well known risk factors for premature cardiovascular events, highlighting the dangers of cocaine use, even in a 'social' setting, and have important public health implications.
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Affiliation(s)
- Rebecca Kozor
- North Shore Heart Research Group, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Stuart M. Grieve
- North Shore Heart Research Group, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Translational Imaging Laboratory, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Stefan Buchholz
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Sharlene Kaye
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Ravinay Bhindi
- North Shore Heart Research Group, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Gemma A. Figtree
- North Shore Heart Research Group, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
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16
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Crack cocaine-induced cardiac conduction abnormalities are reversed by sodium bicarbonate infusion. Case Rep Med 2013; 2013:396401. [PMID: 23762070 PMCID: PMC3677010 DOI: 10.1155/2013/396401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 05/13/2013] [Indexed: 12/27/2022] Open
Abstract
We report a dramatic case of a 19-year-old man with crack cocaine overdose with important clinical complications as cardiac arrest due to ventricular fibrillation and epileptics status. During this intoxication, electrocardiographic abnormalities similar to those found in tricyclic antidepressant poisoning were observed, and they were reversed by intravenous sodium bicarbonate infusion.
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17
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Abstract
The critical care physician is often called to care for poisoned patients. This article reviews the general approach to the poisoned patient, specifically focusing on the utility of the toxidrome. A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison. There are numerous toxidromes defined in the medical literature. This article focuses on the more common toxidromes described in clinical toxicology. Although these toxidromes can aid the clinician in narrowing the differential diagnosis, care must be exercised to realize the exceptions and limitations associated with each.
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Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, Blue Ridge Poison Center, University of Virginia Health System, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA.
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18
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19
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Faa A, Senes G, Locci A, Pampaloni P, Pais ME, Piras B, d'Aloja E, Faa G. S100B protein expression in the heart of deceased individuals by overdose: a new forensic marker? Clinics (Sao Paulo) 2012; 67:821-6. [PMID: 22892929 PMCID: PMC3400175 DOI: 10.6061/clinics/2012(07)19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 03/22/2012] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The evaluation of S100B protein expression in the human heart and its correlation with drug-related death. METHOD Left ventricular samples were collected from 74 serial forensic autopsies (15 overdose-related deaths; 59 non-overdose-related deaths) from 2007 to 2010. Tissue sections from each sample were immunostained for S100B protein by a commercial antibody. RESULTS The S100B protein was detected in the heart samples of all 15 cases of drug-related deaths; S100B immunoreactivity was mainly observed in the cytoplasm of cardiomyocytes and as globular deposits in the interstitial spaces. No reactivity or weak reactivity was found in the cardiomyocytes of the 59 subjects who died of other causes. CONCLUSION Our preliminary data show that the S100B protein accumulates in injured cardiomyocytes during drug-related sudden death. Given the near absence of S100B protein in the heart of subjects who died from causes other than drug overdose, S100B immunopositivity may be used as a new ancillary screening tool for the postmortem diagnosis of overdose-related cardiac death.
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Affiliation(s)
- Armando Faa
- University of Cagliari, Department of Pathology, Cagliari, Italy.
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20
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Ramirez FD, Femenía F, Simpson CS, Redfearn DP, Michael KA, Baranchuk A. Electrocardiographic findings associated with cocaine use in humans: a systematic review. Expert Rev Cardiovasc Ther 2012; 10:105-27. [PMID: 22149529 DOI: 10.1586/erc.11.152] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cocaine remains highly prevalent and accessible in the general population, continues to represent one of the most commonly reported substances in drug-related presentations to emergency departments, and is frequently implicated in drug-related deaths. Fatal cardiac arrhythmias are often suspected in the latter cases. In spite of this, its complex effects on the human cardiac conduction system remain poorly elucidated. In this article we sought to systematically review the medical literature to identify the electrocardiographic findings that have been linked to cocaine use in humans in an effort to highlight what physicians can expect to encounter when managing patients using the drug. The evidence is discussed, common findings are emphasized and clinical recommendations are proposed.
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Affiliation(s)
- F Daniel Ramirez
- Cardiac Electrophysiology and Pacing, Arrhythmia Service, Kingston General Hospital, Queen's University, Kingston, ON, K7L 2V7, Canada
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21
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Hoffman RS. Treatment of patients with cocaine-induced arrhythmias: bringing the bench to the bedside. Br J Clin Pharmacol 2011; 69:448-57. [PMID: 20573080 DOI: 10.1111/j.1365-2125.2010.03632.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Widespread use of cocaine and its attendant toxicity has produced a wealth of benchwork studies and small animal investigations that evaluated the effects of cocaine on the cardiovascular system. Despite this wealth of knowledge, very little is known about the frequency or types of arrhythmias in patients with significant cocaine toxicity. The likely aetiologies; catecholamine excess, sodium channel blockade, potassium channel blockade, calcium channel effects, or ischaemia may act alone or in concert to produce a vast array of clinical findings that are modulated by hyperthermia, acidosis, hypoxia and electrolyte abnormalities. The initial paper in the series by Wood & Dargan providing the epidemiological framework of cocaine use and abuse is followed by a detailed review of the electrophysiological effects of cocaine by O'Leary & Hancox. This review is designed to complement the previous papers and focuses on the diagnosis and treatment of patients with cocaine-associated arrhythmias.
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22
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Affiliation(s)
- Bryan G Schwartz
- Heart Institute, Good Samaritan Hospital, 1225 Wilshire Blvd, Los Angeles, CA 90017-2395, USA
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23
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Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: Pediatric Advanced Life Support. Circulation 2010; 122:S876-908. [DOI: 10.1161/circulationaha.110.971101] [Citation(s) in RCA: 473] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Brubacher J. Bicarbonate therapy for unstable propafenone-induced wide complex tachycardia. CAN J EMERG MED 2010; 6:349-56. [PMID: 17381993 DOI: 10.1017/s1481803500009635] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A previously healthy 73-year-old woman presented to hospital with acute atrial fibrillation. After intravenous procainamide failed to restore sinus rhythm, she was treated with 300 mg of oral propafenone and discharged with a prescription for propafenone and propranolol. Six hours later she took 150 mg of propafenone as prescribed. Within 1 hour she became dyspneic and collapsed. On arrival in hospital she was unconscious, with a wide complex tachycardia and no obtainable blood pressure. After defibrillation and lidocaine, she converted to a wide complex sinus rhythm, but remained profoundly hypotensive despite intravenous epinephrine and dopamine. Hypertonic sodium bicarbonate (HCO3) was administered and, shortly thereafter, her blood pressure increased, her QRS duration normalized and her clinical status improved dramatically. In this case of severe refractory propafenone-related cardiac toxicity, intravenous HCO3 led to a profound clinical improvement. Emergency physicians should be familiar with the syndrome of sodium-channel blocker poisoning and recognize the potentially important role of bicarbonate in its treatment.
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Affiliation(s)
- Jeff Brubacher
- Vancouver General Hospital, Vancouver, British Columbia, Canada.
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25
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Wood SK, Narasimhan D, Cooper Z, Sunahara RK, Woods JH. Prevention and reversal by cocaine esterase of cocaine-induced cardiovascular effects in rats. Drug Alcohol Depend 2010; 106:219-29. [PMID: 19800183 PMCID: PMC3349347 DOI: 10.1016/j.drugalcdep.2009.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 09/02/2009] [Accepted: 09/02/2009] [Indexed: 11/25/2022]
Abstract
The present study is the first to utilize bacterial cocaine esterase (CocE) to increase elimination of a lethal dose of cocaine and evaluate its cardioprotective effects. Rats received one of 5 treatments: CocE 1 min after saline; CocE 1 min after a lethal i.p. dose of cocaine; saline 1 min after a lethal i.p. dose of cocaine; CocE immediately after observing a cocaine-induced convulsion; and CocE 1 min after observing a cocaine-induced convulsion. Measures were taken of ECG, blood pressure, and cardiac troponin I (cTnI). The specificity of CocE against cocaine was determined by evaluating its actions against the cocaine analogue, WIN-35,065-2, which lacks an ester attack point for CocE. In addition, CocE's effects were compared with those of midazolam, a benzodiazepine often used to manage cocaine overdose. Whereas CocE alone had negligible cardiovascular effects, it blocked or reversed cocaine-induced QRS complex widening, increased QTc interval, ST elevation, bradycardia, and hypertension. When administered 1 min after cocaine, CocE inhibited myocardial damage; however, administered 1 min after a cocaine-induced convulsion (approximately 40s before cocaine-induced death), CocE did not block cTnI release, but did restore cardiac function. Midazolam blocked convulsions, but exhibited inadequate protection against cocaine-induced cardiotoxicity. The majority of rats given cocaine plus midazolam died. CocE did not prevent the lethal cardiovascular effects of WIN-35,065-2. In all likelihood, CocE rapidly and specifically reduced the body burden of cocaine and inhibited or reversed the cardiovascular consequences of high-dose cocaine. These results support CocE as a potential therapeutic avenue in cocaine overdose.
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Affiliation(s)
| | | | | | | | - James H. Woods
- Corresponding author at: Department of Pharmacology, The University of Michigan Medical School, 1301 Medical Science Research Building III, 1150 W. Medical Center Dr., Ann Arbor, MI 48109-0632, USA. Tel.: +1 734 764 9133; fax: +1 734 764 7118. (J.H. Woods).
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26
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Severe central nervous system and cardiovascular toxicity in a pediatric patient after ingestion of an over-the-counter local anesthetic. Pediatr Emerg Care 2009; 25:670-3. [PMID: 19834416 DOI: 10.1097/pec.0b013e3181b91e8c] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dibucaine is considered one of the most potent and consequently toxic amide anesthetics available, and despite withdrawal from the US market as a spinal anesthetic, it remains accessible as an over-the-counter preparation in the United States. Dibucaine exposures in children are infrequently encountered, but to date, all reported consequential ingestions have resulted in death. We report the first case of a potentially fatal dibucaine-induced wide-complex arrhythmia in a child who survived her clinical course without sequelae. It is our hope that this report will highlight the toxicity of dibucaine and prompt a review of its over-the-counter status. The rationale and success of a new antidote, 20% lipid emulsion, for the management of local anesthetic toxicity is discussed.
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27
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Life threatening hyperkalemia following cocaine ingestion: a case report. CASES JOURNAL 2009; 2:7355. [PMID: 19829947 PMCID: PMC2740065 DOI: 10.4076/1757-1626-2-7355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 06/08/2009] [Indexed: 11/16/2022]
Abstract
We present a case of life-threatening hyperkalemia after recreational cocaine ingestion. Acute cocaine-induced rhabdomyolysis led to hyperkalemia, cardiac arrhythmias and cardiogenic shock resulting in multi-organ failure.
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28
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Wood DM, Dargan PI, Hoffman RS. Management of cocaine-induced cardiac arrhythmias due to cardiac ion channel dysfunction. Clin Toxicol (Phila) 2009; 47:14-23. [PMID: 18815938 DOI: 10.1080/15563650802339373] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cocaine use is common in many areas of the world, particularly the United States and Western Europe. Toxicity following the use of cocaine is associated with a wide range of clinical features. In this review, we will focus on the cocaine-associated cardiac arrhythmias and, in particular, some of the controversies in their etiology and management. Cocaine can produce arrhythmias either through the production of myocardial ischemia or as a direct result of ion channel alterations. Excessive catecholamines, combined with sodium and potassium channel blockades, give rise to a wide variety of supra-ventricular and ventricular rhythms. The animal and human evidence for ion channel dysfunction is reviewed, and the effects of catecholamines are followed from the cardiac action potential to the development of arrhythmias. Finally, theoretical constructs are combined with existing evidence to develop a rational treatment strategy for patients with cocaine-induced cardiac arrhythmias. In particular, we review the evidence concerning the controversies relating to the use of lidocaine in comparison with sodium bicarbonate, in terms of QRS prolongation secondary to sodium channel blockade.
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Affiliation(s)
- David M Wood
- Guy's and St Thomas' Poisons Unit, Guy's and St Thomas NHS Foundation Trust, London, UK.
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29
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Kalimullah EA, Bryant SM. Case files of the medical toxicology fellowship at the toxikon consortium in Chicago: cocaine-associated wide-complex dysrhythmias and cardiac arrest - treatment nuances and controversies. J Med Toxicol 2008; 4:277-83. [PMID: 19031381 PMCID: PMC3550110 DOI: 10.1007/bf03161213] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A 19-year-old woman was brought by ambulance to the emergency department (ED) from a police holding cell. Less than 3 hours earlier, the patient had been a passenger in a car stopped for a traffic violation. As the police officer approached the car, the patient was noted to hurriedly stuff 2 plastic bags containing a white powdery substance into her mouth. On questioning, it was reported that the packets contained cocaine. Less than an hour after being taken to the police station, the patient was witnessed to have a generalized seizure. What is the pharmacological basis of acute cocaine intoxication? What are the cardiovascular manifestations of acute cocaine intoxication? What is the basis for using sodium bicarbonate in cocaine-induced wide-complex dysrhythmias? What is the basis for the use of lidocaine in cocaine-induced wide-complex dysrhythmias? Is there any evidence for the use of amiodarone to treat cocaine-induced wide-complex dysrhythmias?
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Affiliation(s)
- Ejaaz A. Kalimullah
- />Toxikon Consortium, Cook County-Stroger Hospital, USA
- />Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL
| | - Sean M. Bryant
- />Toxikon Consortium, Cook County-Stroger Hospital, USA
- />Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL
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30
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Abstract
Emergency physicians are regularly called on to care for critically poisoned patients. This article reviews the general approach and management of the critically poisoned patient. Specific clinical characteristics are identified that may clue the clinician into a specific toxin class as a diagnosis. Appropriate testing in the poisoned patient is reviewed. Complications of poisoning that may bring a rapid demise of the critically ill poisoned patient are highlighted and the management of those complications is discussed.
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McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P, Gibler WB, Ohman EM, Drew B, Philippides G, Newby LK. Management of Cocaine-Associated Chest Pain and Myocardial Infarction. Circulation 2008; 117:1897-907. [PMID: 18347214 DOI: 10.1161/circulationaha.107.188950] [Citation(s) in RCA: 265] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lester L, McLaughlin S. SALT: A Case For the Sodium Channel Blockade Toxidrome and the Mnemonic SALT. Ann Emerg Med 2008; 51:214. [DOI: 10.1016/j.annemergmed.2007.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 09/12/2007] [Accepted: 09/17/2007] [Indexed: 11/29/2022]
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Heard K, Palmer R, Zahniser NR. Mechanisms of acute cocaine toxicity. THE OPEN PHARMACOLOGY JOURNAL 2008; 2:70-78. [PMID: 19568322 PMCID: PMC2703432 DOI: 10.2174/1874143600802010070] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 07/07/2008] [Accepted: 07/14/2008] [Indexed: 11/22/2022]
Abstract
Patients with acute cocaine poisoning present with life-threatening symptoms involving several organ systems. While the effects of cocaine are myriad, they are the result of a limited number of cocaine-protein interactions, including monoamine transporters, neurotransmitter receptors and voltage-gated ion channels. These primary interactions trigger a cascade of events that ultimately produce the clinical effects. The purpose of this article is to review the primary interactions of cocaine and the effects that these interactions trigger. We also describe the progression of symptoms observed in cocaine poisoning as they relate to serum cocaine concentrations.
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Affiliation(s)
- Kennon Heard
- Rocky Mountain Poison and Drug Center, Denver Health
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Abstract
PURPOSE OF REVIEW The following review intends to outline the unique aspects of providing cardiopulmonary resuscitation for the poisoned patient and highlights both current practice and new therapies that apply to toxicologic cases. RECENT FINDINGS Although there are few prospective randomized studies to further evidence-based care of the poisoned patient, there have been several reports of novel uses of both established medications and new medications in toxicologic patients. These case reports highlight treatment possibilities and potential avenues for further research. SUMMARY It is important for providers to recognize the limitations of standard advanced cardiac life support algorithms when caring for poisoned patients. Toxicologic causes of cardiopulmonary compromise should be considered along with administration of appropriate antidotes and adjunctive therapies.
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Affiliation(s)
- Melissa L Givens
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington 98431, USA.
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35
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Bebarta VS, Summers S. Brugada Electrocardiographic Pattern Induced by Cocaine Toxicity. Ann Emerg Med 2007; 49:827-9. [PMID: 17512876 DOI: 10.1016/j.annemergmed.2007.01.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Revised: 12/20/2006] [Accepted: 01/16/2007] [Indexed: 10/23/2022]
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Hsue PY, McManus D, Selby V, Ren X, Pillutla P, Younes N, Goldschlager N, Waters DD. Cardiac arrest in patients who smoke crack cocaine. Am J Cardiol 2007; 99:822-4. [PMID: 17350374 DOI: 10.1016/j.amjcard.2006.10.044] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 10/30/2006] [Accepted: 10/30/2006] [Indexed: 11/16/2022]
Abstract
The aim of the study is to determine the clinical features and outcomes of cocaine users admitted to the hospital after cardiac arrest and compare them with nonusers. Cocaine is associated with cardiovascular complications, including ventricular arrhythmias; however, resuscitated cardiac arrest in relation to cocaine use is not a well-defined clinical entity. We reviewed available hospital charts at San Francisco General Hospital with the International Classification of Diseases, Ninth Revision diagnosis of cardiac arrest and cocaine use from 1994 to 2006. Clinical features and outcomes of cocaine users were compared with those of randomly selected control patients and age-matched controls with resuscitated cardiac arrest without cocaine use. We identified 22 patients with resuscitated cardiac arrest in the setting of cocaine use. Their average age was 42 +/- 10 years, >20 years younger than nonusers (68 +/- 16 years, p <0.01). After cardiac arrest, 12 of 22 patients (55%) who used cocaine had complete neurologic recovery in contrast to only 3 of 20 unmatched controls (15%, p <0.01) and 7 of 41 age-matched controls (17%, p <0.01). Only 10 of 22 cocaine users (46%) died compared with 15 of 20 unmatched controls (75%, p = 0.05) and 32 of 41 age-matched controls (78%, p <0.01). In a combined analysis of all patients, cocaine use was the only significant predictor of neurologic recovery (p <0.01) and survival (p <0.01). In conclusion, cocaine use is associated with cardiac arrest. In patients with cardiac arrest, cocaine users are younger than nonusers and more likely to survive with neurologic recovery, even compared with age-matched controls with cardiac arrest.
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Affiliation(s)
- Priscilla Y Hsue
- Division of Cardiology, San Francisco General Hospital, San Francisco, California, USA
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37
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Coughlin PA, Mavor AID. Arterial Consequences of Recreational Drug Use. Eur J Vasc Endovasc Surg 2006; 32:389-96. [PMID: 16682239 DOI: 10.1016/j.ejvs.2006.03.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Accepted: 03/02/2006] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recreational drug use is becoming an increasing problem throughout the world. Many of the drugs used and their routes of administration have the potential to cause damage to the vascular system. Intravenous drug administration with the risk of arterial puncture predisposes to the formation of infected pseudoaneurysms. Inadvertent intra-arterial injection predisposes to distal limb ischaemia. Cocaine has numerous effects not only on the heart, but also potentially on any vascular bed. METHODS A systematic review of published literature with regard to the arterial consequences of recreational drug abuse was undertaken by undergoing an electronic search. RESULTS Most of the available literature is in the form of case reports and case series. Pseudoaneurysm formation is a serious consequence for intravenous drug users. For femoral aneurysms vessel ligation is the safest option with a low amputation risk. A high proportion of patients do have symptoms of claudication in the long term. Intra-arterial injections can result in limb threatening ischaemia. Systemic anticoagulation forms the mainstay of treatment. Cocaine has significant effects upon both the myocardium and the arterial tree in general. Arterial problems must always be considered in cocaine users who present acutely. CONCLUSION The consequences of recreational drug use will result in an increased exposure of vascular surgeons to its associated complications posing unique and challenging problems.
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Affiliation(s)
- P A Coughlin
- Department of Vascular Surgery, Leeds General Infirmary, Leeds, England, UK.
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38
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2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support. Pediatrics 2006; 117:e1005-28. [PMID: 16651281 DOI: 10.1542/peds.2006-0346] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Despite that drugs have widely varying indications for therapeutic use, many unrelated drugs share a common cardiac pharmacologic effect if taken in overdose. The purpose of this article is to group together agents that cause similar electrocardiographic effects,review their pharmacologic actions, and discuss the electrocardiographic findings reported in the medical literature.
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Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, P.O. Box 800774, Charlottesville, VA 22908-0774, USA.
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Abstract
Patients who have chest pain following the use of cocaine have become more common in emergency departments throughout the United States,with approximately 6% of these patients sustaining an acute MI. The authors have described the rationale for recommending aspirin, benzodiaze-pines, and nitroglycerin as first-line treatments and calcium-channel blockade or phentolamine as possible second-line therapies and have summarized the controversies surrounding the use of fibrinolytic agents. Admission for observation is one reasonable approach to the management of the low-risk cohort. Evaluation for underlying coronary artery disease is reasonable, particularly in patients who have acute MI. Patients who do not have infarction can undergo evaluation for possible coronary artery disease on an outpatient basis. Routine interventions for secondary prophylaxis as well as cocaine rehabilitation should be used in this patient population, because the long-term prognosis seems somewhat dependent upon the ability of the patient to discontinue cocaine use.
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Affiliation(s)
- Judd E Hollander
- Department of Emergency Medicine, University of Pennsylvania, Ground Floor, Ravdin Building, 3400 Spruce Street Philadelphia, PA 19104-4283, USA
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Seger DL. A Critical Reconsideration of the Clinical Effects and Treatment Recommendations for Sodium Channel Blocking Drug Cardiotoxicity. ACTA ACUST UNITED AC 2006; 25:283-96. [PMID: 17288499 DOI: 10.2165/00139709-200625040-00008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The cardiac sodium channel is comprised of proteins that span the cardiac cell membrane and form the channel pore. Depolarisation causes the proteins to move and open the sodium channel. Once the channel is open (active conformation), sodium ions move into the cell. The channel then changes from the active conformation to an inactive conformation - the channel remains open, but influx of sodium ions ceases. Recovery occurs as the channel moves from the inactive conformation back to the closed conformation and is then ready to open following the next depolarisation. Sodium channel blocking drugs (NCBDs) occupy receptors in the channel during the active and inactive conformations. The drug dissociates from most of the channel receptors during recovery, but the time it takes the drug to dissociate slows recovery. The slowed recovery prolongs conduction time, the main toxicity of NCBD overdose. Conduction time is further prolonged if heart rate increases as there are more available active and inactive conformations/unit time, which increases channel receptor binding sites for the NCBD. In addition to prolonging conduction time, NCBDs also decrease inotropy. Treatment of NCBD cardiotoxicity has been based on in vitro and animal experiments, and case reports. Assumptions based on this evidence must now be reassessed. For example, canines consistently develop ventricular tachycardia (VT) when tricyclic antidepressants (TCAs) are administered. Much of the literature discussing NCBD cardiotoxicity assumes that TCA poisoning induces VT in humans with the same regularity that occurs in canines. Seemingly, in support of this assumption was the finding that patients with remote myocardial infarction developed VT when therapeutically ingesting a NCBD. However, conduction is prolonged in myocardium that is or has been ischaemic. NCBD prolong conduction more in previously ischaemic myocardium than in normal myocardium, which causes nonuniform conduction and allows the development of re-entrant arrhythmias such as VT. Although some nonuniform conduction may occur in the healthy heart following a NCBD overdose, there is no evidence that nonuniform conduction occurs to the extent that it will cause re-entrant arrhythmias in this setting. Using various animal models and a variety of NCBDs, sodium ions, bicarbonate ions and alkalosis have been compared for the treatment of ventricular arrhythmias, hypotension and mortality. The results of these experiments have been extrapolated to NCBD overdose in humans. Animal models and single treatment approaches may have narrowed our scope. More recent evidence indicates that properties of each individual NCBD may require unique treatment. There is limited evidence that glucagon, which increases initial sodium ion influx into the cardiac cell, should be considered early in the treatment of cardiotoxicity. Another consideration may be treatment of NCBD with faster kinetics. Conduction time is decreased if a NCBD occupying the receptor is replaced by a NCBD that moves off and on the receptor more quickly. There is less evidence for this treatment, as risk may be greater. With greater understanding of the sodium channel and NCBDs, we must reassess our approach to the treatment of patients with healthy hearts who overdose on NCBD.
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DeWitt CR, Cleveland N, Dart RC, Heard K. The effect of amiodarone pretreatment on survival of mice with cocaine toxicity. J Med Toxicol 2005; 1:11-8. [PMID: 18072097 PMCID: PMC3550010 DOI: 10.1007/bf03160899] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Cocaine is a common drug of abuse and use has been associated with ventricular dysrhythmias. Published guidelines suggest that amiodarone is the first line antidysrhythmic for ventricular tachycardia and fibrillation. However, the effects amiodarone in the setting of cocaine toxicity are unknown and unstudied. The purpose of this study was to evaluate the safety and efficacy of amiodarone pretreatment in a murine model of acute cocaine toxicity. METHODS This was a randomized, blinded, placebo controlled investigation using male CF-1 mice weighing 29-37 g. First, the safety of an intraperitoneal dose of amiodarone (40 mg/kg) was confirmed in 5 mice. Second, based on preliminary investigations, an approximate intraperitoneal LD50 dose of cocaine (110 mg/kg) was identified and used as the cocaine dose in this study. Animals were then randomized to 2 groups. The control group received 0.5 mL of intraperitoneal 0.9% saline 30 minutes before cocaine. The study group received 40 mg/kg of intraperitoneal amiodarone (40 mg/kg) 30 minutes before cocaine. A blinded observer monitored mice for 2 hours after cocaine administration. RESULTS No mice in the amiodarone-only group developed any signs of toxicity or died. In the saline + cocaine group 31/32 (96.9%; 95% CI 83.8 to 99.9) mice seized with a median time to seizure of 2.5 minutes, and 23/32 (71.9%; 95% CI 52.3 to 86.3) died with a median time to death of 5.5 minutes. In the amiodarone + cocaine group 31/33 (93.9%; 95% CI 79.0 to 99.3) mice seized with a median time to seizure of 2.0 minutes, and 24/33 (72.7%; 95% CI 54.5 to 86.7) died with a median time to death of 6.0 minutes. All animals that died did so within 9 minutes. The difference in the proportion of animals dying in the amiodarone + cocaine group compared to the saline + cocaine group was 0.008 (-21 to 22%). CONCLUSIONS In this study, pretreatment with amiodarone in cocaine poisoned mice resulted in no change in seizure incidenceor mortality. However, definite conclusions about the reason for these findings cannot be drawn from this model.
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Affiliation(s)
- Christopher R. DeWitt
- />Rocky Mountain Poison and Drug Center and Denver Health Medical Center, Denver, CO
- />University of Colorado Health Sciences Center and University of Colorado Emergency Medicine Research Center, Denver, CO
| | - Nathan Cleveland
- />University of Colorado School of Medicine and Colorado Emergency Medicine Research Center, Denver, CO
| | - Richard C. Dart
- />Rocky Mountain Poison and Drug Center, Denver Health Medical Center, Denver, CO
- />University of Colorado Health Sciences Center, Denver, CO
| | - Kennon Heard
- />Division of Emergency Medicine, University of Colorado Health Sciences Center and Colorado Emergency Medicine Research Center, Denver, CO
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Eldridge DL, Dobson T, Brady W, Holstege CP. Utilizing diagnostic investigations in the poisoned patient. Med Clin North Am 2005; 89:1079-105. [PMID: 16227055 DOI: 10.1016/j.mcna.2005.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Numerous diagnostic tests may be useful to clinicians caring for poisoned patients. Clinicians should not order a broad range of tests indiscriminately,but rather thoughtfully consider appropriate tests. The results'of the tests should be reviewed in the context of the clinical scenario.
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Affiliation(s)
- David L Eldridge
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Attaran R, Ragavan D, Probst A. Cocaine-related myocardial infarction: concomitant heroin use can cloud the picture. Eur J Emerg Med 2005; 12:199-201. [PMID: 16034268 DOI: 10.1097/00063110-200508000-00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cocaine-related myocardial infarction is a well-known phenomenon. Concurrent heroin use can mask signs and symptoms of myocardial infarction. We discuss an unusual presentation of myocardial infarction, associated with both cocaine and heroin ("speedball") self-injection, that initially went undiagnosed.
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Affiliation(s)
- Robert Attaran
- University of Arizona Affiliated Hospitals, University Medical Center, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA.
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Ortega-Carnicer J, Gómez-Grande L, Ambrós A. Electrocardiographic changes indicating surgery on cocaine body-packers. Resuscitation 2005; 65:373-4. [PMID: 15919577 DOI: 10.1016/j.resuscitation.2004.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Accepted: 12/16/2004] [Indexed: 11/16/2022]
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Abstract
Cocaine abuse in the United States is widespread, affecting more than 30 million people. Nearly 90% of cocaine-abusing women are of childbearing age. Cardiovascular complications of cocaine intoxication include dysrhythmias, ischemia and/or infarction, and account for most cocaine-related deaths. Pregnancy enhances the cardiovascular toxicity of cocaine. While the epidemiology, pathophysiology, clinical symptomatology and implications on pregnancy of cocaine addiction in pregnancy have received significant attention over the past 25 years, far too little attention has been given to the therapeutic considerations and peripartum care of the cocaine-abusing parturients. The timely treatment of acute cocaine-induced cardiovascular toxicity in pregnancy is by far the best predictor of good maternal and fetal outcome. However, no specific treatment guidelines are currently available for cocaine-induced cardiac dysrhythmias. This article discusses briefly several agents (and considers their mechanism of action) that have been proposed for the treatment of chest pain and other cardiovascular side-effects of cocaine toxicity in pregnancy.
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Affiliation(s)
- Krzysztof M Kuczkowski
- Departments of Anesthesiology and Reproductive Medicine, UCSD Medical Center, University of California-San Diego, 200 W. Arbor Drive, San Diego, CA 92103-8770, USA.
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Decerf JA, Gressens B, Brohet C, Liolios A, Hantson P. Can methadone prolong the QT interval? Intensive Care Med 2004; 30:1690-1. [PMID: 15185068 DOI: 10.1007/s00134-004-2335-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2004] [Indexed: 11/29/2022]
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Wilson LD, Shelat C. Electrophysiologic and Hemodynamic Effects of Sodium Bicarbonate in a Canine Model of Severe Cocaine Intoxication. ACTA ACUST UNITED AC 2003; 41:777-88. [PMID: 14677787 DOI: 10.1081/clt-120025342] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Cocaine toxicity causes myocardial depression, malignant dysrhythmias, and sudden death, partially due to cocaine-related myocardial sodium channel blockade. Because of cocaine's ability to block cardiac sodium channels, sodium bicarbonate (NaHCO3) has been proposed as an antidote. The hypothesis of this study was that NaHCO3 would correct cocaine-induced conduction abnormalities and resultant hemodynamic compromise in an animal model simulating severe cocaine intoxication. METHODS DESIGN Prospective, controlled, experimental study in which 15 anesthetized dogs were given three successive boluses of cocaine (7 mg/kg) and then randomized to receive NaHCO3, 2 mEq/kg (n = 8) or placebo (n =7). MEASUREMENTS Arterial, left ventricular, and pulmonary artery pressures; cardiac output (CO); electrocardiogram (ECG); blood gases; and serum concentrations of cocaine were measured at baseline, at fixed time intervals after each bolus of cocaine, and then after administration of NaHCO3 or placebo. Statistical significance was determined by analysis of variance (ANOVA) for repeated measures. RESULTS Seven dogs experienced significant arrhythmias, including VT, pulseless electrical activity, and third-degree atrioventricular block; 2 of these dogs expired prior to receiving NaHCO3 and were excluded. Immediately after administering NaHCO3, QRS duration decreased by 30% (p < 0.001), returning to baseline more quickly than in the control group. This effect was associated with a brief 30% decrease in MAP (p = NS). After NaHCO3, CO increased 78% and remained increased for 5 min (p < 0.007). One dog converted from complete heart block to sinus rhythm shortly after NaHCO3 administration. CONCLUSIONS NaHCO3 improved ECG changes secondary to cocaine toxicity and improved myocardial function.
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Affiliation(s)
- Lance D Wilson
- Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, Ohio 44109, USA.
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Dackis CA, Lynch KG, Yu E, Samaha FF, Kampman KM, Cornish JW, Rowan A, Poole S, White L, O'Brien CP. Modafinil and cocaine: a double-blind, placebo-controlled drug interaction study. Drug Alcohol Depend 2003; 70:29-37. [PMID: 12681523 DOI: 10.1016/s0376-8716(02)00335-6] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Modafinil is a novel compound that is approved for the treatment of narcolepsy. It is now being studied as a potential treatment for cocaine dependence. Cocaine withdrawal symptoms are associated with poor clinical outcome and are likely to be reversed by modafinil. In addition, the neurotransmitter actions of modafinil are opposite to cocaine-induced neuroadaptations affecting dopamine and glutamate reward circuits. Since cocaine-dependent subjects might use cocaine during a clinical trial with modafinil, this study tested the safety of intravenous cocaine (30 mg) in combination with modafinil. Each of seven subjects received a baseline (open-label) cocaine infusion. Three subsequent cocaine infusions were administered after subjects received 4 days of low dose modafinil (200 mg/day), high dose modafinil (400 mg/day), or placebo in randomized double-blind sequences. One subject received placebo prior to all infusions. Our results indicate that co-administering modafinil and a single dose of intravenous cocaine is not associated with medical risk in terms of blood pressure, pulse, temperature, or electrocardiogram measures. Furthermore, pretreatment with modafinil did not intensify cocaine euphoria or cocaine-induced craving. In fact, cocaine euphoria was significantly blunted (P=0.02) in one of our subjective measures.
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Affiliation(s)
- Charles A Dackis
- Department of Psychiatry, University of Pennsylvania, 3900 Chestnut Street, Philadelphia, PA 19104, USA.
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Littmann L, Monroe MH, Kerns WP, Svenson RH, Gallagher JJ. Brugada syndrome and "Brugada sign": clinical spectrum with a guide for the clinician. Am Heart J 2003; 145:768-78. [PMID: 12766732 DOI: 10.1016/s0002-8703(03)00081-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with the manifest Brugada syndrome have an inordinate risk of sudden death and are candidates for implantation of a defibrillator. The Brugada type electrocardiogram (ECG) abnormality (the "Brugada sign"), however, is known to be associated with a wide range of conditions, many of which may not pose such a threat. Clinicians need guidance in choosing a rational approach for the evaluation and treatment of patients with a finding of the Brugada sign. METHODS A systematic literature search was performed to identify publications on the Brugada syndrome and the Brugada-type ECG abnormality, with special emphasis on analyzing outcomes data. In addition, the ECG database of our institution was reviewed for tracings consistent with the Brugada sign, and, when possible, clinical correlations were made. RESULTS Patients with the Brugada sign and a family history of sudden death or a personal history of syncope are at a high risk of sudden death and therefore should be strongly considered for implantation of a defibrillator. In patients who are hospitalized and critically ill, the Brugada sign is frequently the result of severe hyperkalemia, drug toxicity, or right ventricular injury. In most individuals with no symptoms and without a family history of sudden death, the Brugada sign is likely a normal variant. CONCLUSIONS Most patients with the Brugada sign can be risk-stratified with simple clinical tools. Specific testing for the Brugada syndrome should be reserved for questionable cases and for the research setting. A provisional diagnostic-therapeutic algorithm is offered as a means of assisting the clinician in the evaluation and treatment of patients with the Brugada sign.
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Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC 28232, USA.
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