Crack cocaine ingestion with prolonged toxicity requiring electrical pacing

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

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.

A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use

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.

Treatment of cocaine cardiovascular toxicity: a systematic review

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.

A case of heatstroke complicated by persistent ventricular tachycardia

BACKGROUND

Patients suffering from heatstroke often present with electrocardiograph abnormalities, but persistent ventricular tachycardia has not been reported previously.

OBJECTIVE

This report is intended to demonstrate that rapid and effective cooling is critical to survival in patients experiencing heatstroke with ventricular tachycardia.

CASE

We cared for a healthy 38-year-old man with environmentally induced heatstroke, who presented with ventricular tachycardia resistant to cardioversion until his core body temperature was reduced significantly.

CONCLUSIONS

This case represents the first report of ventricular tachycardia occurring in a patient with heatstroke. Successful cardioversion could not be achieved until his core body temperature was lowered significantly, reinforcing the need for rapid temperature reduction that can be accomplished through noninvasive means.

Electrocardiographic findings associated with cocaine use in humans: a systematic review

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.

Clinical profiles, complications, and disability in cocaine-related ischemic stroke

Cocaine use is associated with ischemic stroke through unique mechanisms, including reversible vasospasm, drug-induced arteritis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. To date, no study has described disability in patients with cocaine-related ischemic stroke. The present study compared risk factors, comorbidities, complications, laboratory findings, medications, and outcomes in patients with cocaine-related (n = 41) and non-cocaine-related (n = 221) ischemic stroke (n = 147) and transient ischemic attack (n = 115) in 3 academic hospitals. The patients with cocaine-related stroke were younger (mean age, 51.9 years vs 59.1 years; P = .0008) and more likely to be smokers (95% vs 62.9%; P < .004). The prevalence of arrhythmias was significantly higher in the patients with cocaine-related stroke, and that of diabetes was significantly higher in those with non-cocaine-related strokes. The prevalence of hypertension and lipid profiles were similar in the 2 groups; however, those with cocaine-related stroke were less likely to receive statins. Antiplatelet use was similar in the 2 groups. Survivors of both groups had similar modified Rankin scores and lengths of hospital stay. In the older urban population, smoking and cocaine use may coexist with other cerebrovascular risk factors, and cocaine-related strokes have similar morbidities and mortality as non-cocaine-related strokes. Moreover, because the patients with cocaine-related stroke is younger, they have an earlier morbidity. New strategies for effective stroke prevention interventions are needed in this subgroup.

Management of dofetilide overdose in a patient with known cocaine abuse

Dofetilide, a class III antiarrhythmic agent, is prescribed for conversion to and maintenance of normal sinus rhythm in patients with persistent atrial fibrillation or atrial flutter. Most antiarrhythmics have significant toxicities such as torsade de pointes, and patients should be closely monitored while receiving antiarrhythmic therapy. However, we know of no reports concerning management of intentional overdose of dofetilide that have been published. We report the case of a 33-year-old man who was treated for ingestion of approximately 5 mg of dofetilide as a suicide attempt. In addition, he had a known history of cocaine abuse. He came to the emergency department approximately 45 minutes after the ingestion; examination revealed a QTc interval of approximately 570 msec. He was treated with activated charcoal and sorbitol by nasogastric tube and received aggressive supplementation with potassium and magnesium. The patient was monitored by telemetry for several days and responded well. Cardiac toxicity is the utmost concern when treating dofetilide overdose. The mainstay of treatment focuses on supportive care and prevention of drug absorption. Ventricular dysrhythmias or torsade de pointes should be treated according to advanced cardiac life support guidelines.