cocaine alkaloids

8/8/2019 Cocaine Alkaloids

1/5

1990;86;117-119PediatricsSIGMUND KHARASCH, ROBERT VINCI and ROBERT REECE

Child Abuse?Esophagitis, Epiglottitis, and Cocaine Alkaloid ("Crack"): "Accidental" Poisoning or

http://www.pediatrics.orgthe World Wide Web at:

The online version of this article, along with updated information and services, is located on

Online ISSN: 1098-4275.Copyright 1990 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.

American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by thePEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it

. Provided by Indonesia:AAP Sponsored on September 5, 2009www.pediatrics.orgDownloaded from
http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/


2/5

PED IATR IC S V o l. 8 6 N o . 1 Ju ly 1990 117

EXPER IENCE AND REASON -B rie fly R eco rded In M ed ic in e one m us t p ay a tte n tio n no t to p la u s ib le the o riz ing bu t to expe rie nce and re asontoge the r . . . . I a g ree tha t the o r iz ing is to b e app roved , p rov ide d tha t it is ba sed on fac ts , a ndsy s tem atic a lly m akes its d educ tio ns from w ha t is ob se rve d . . . . B ut c on c lus ion s d raw n fromuna id ed re ason can ha rd ly be se rv ice ab le ; o n ly tho se d raw n from obse rve d fa c t. Hippocra tes :P recep ts . (S ho rt com mun ica tions o f fac tua l m ate r ia l a re pub lished he re . C om men ts and critic ism sappea r as Le tte rs to the E dito r.)

Esophag itis , E p ig lo ttitis , andCoca ine A lka lo id (C rack):A cc iden ta l P o ison ing o rC h ild A buse?

A cu te e ffec ts o f co ca in e ab use hav e b een fre -qu en tly d esc r ibed in the m ed ica l lite ratu re . M yo -card ia ! in farc tio n , an g ina , che s t pa in , d ysrhy th -m ias, pneum o thorax , se izu res , and hypertens io nare n o t uncomm on ly seen w ith th e g row in g num be rof d ru g abu se rs in th is cou n try .2 O the r sy stem ice ffects o f co cain e tox icity , inc lud in g m a lig nan t h y -p erthe rm ia , rhabd om yo!ysis , an d ce reb ra l vascu la racc id en ts have been de scrib ed w ith acu te cocaineintoxicat ion.3

W ith th e recen t cocaine a lk alo id ( c rack ) ep i-dem ic , a new sp ec trum of m ed ical a s w e ll as so cia lcon seq uences h ave o ccu rred . T een age v io len ce anddea th hav e been g iv en em phas is b y the lay p ress a saccou n ts o f drug w ars con tinu e to ap pear in p rin t.T h ere is lit tle in fo rm a tion , h ow eve r, id en tify ingch ild ren as v ic tim s o f ab use an d n eg lec t w h ile th eyare in the care o f pe rson s ab usin g crack . In a recen trepo rt4 it w as sugg es ted tha t in fan ts and ch ild renm ay be po ison ed by passive inh ala tion of crackvapo rs , w ith su bsequ en t seizu re s from co cain e tox -ic ity . W e describ e th e ca se o f a 20 -m on th -o ld g irlw ith u ppe r a irw ay and eso ph ag ea l bu rns secon da ryto chem ica ls in vo lved in a cu rren t fo rm of cocaineabuse ; free -basin g .

Rece iv ed fo r pub lica tion Ju l 10 , 1 989 ; accep ted Sep 25 , 19 89 .R eprin t reques ts to (S .K .) D ep t o f P ed iatric s , B oston C ity H o s-p ita ls, 818 H arrison A ye , B os ton , M A 02118 .PED IA TR ICS (ISSN 0031 4005). Copyright 1990 by theA merican A cadem y o f Ped ia tric s.

CASE REPORTS .F ., a 20-m on th -o ld g irl, w as brough t to the em ergency

room w ith a recen t h is to ry o f d roo ling , vom iting , andin te rm itten t le th argy . T he m other repor ted hav ing aparty a t h er apartm en t the n igh t befo re and adm itted toa lco ho l be ing presen t b u t den ied any d rug use . A t 7 AMthe day of adm ission the m o th er aw ok e to feed h er babybreakfas t. T he m o th er then to ok a nap , leav ing S .F .una ttended in th e apartm en t. Severa l hours la te r them other aw oke to f in d the ch ild a t the k itchen tab le,d ro o lin g and vom iting . N ear the ch ild w as a cup ofb row nish liqu id tha t the m o th er b ro ugh t to the em er-gency room . W hen first seen in the em erg en cy room , thech ild appeared to b e hav ing a tox ic reac tion an d w assitting fo rw ard an d droo ling . S he w as n o t s trid o rous o rdyspne ic bu t had tw o ep iso des of gua iac pos itive em es is .Her tem pera tu re w as 36 .6 vC , he r pu lse w as 13 6 bea ts pe rm inu te , he r resp ira to ry ra te w as 44 brea thes per m inu te ,and her b lood pressu re w as 92 sy sto lic /fib d iasto lic . Sh ew as le tha rg ic bu t eas ily arousab le . E xam ina tion o f them outh and oral phary nx revea led m ultip le w h ite burn sof the h ard pa la te as w ell as edem a o f the uv u la and softpa la te . R esu lts o f exam ina tion of the heart, lu ngs , andabdom en w ere no rm al. R esu lts o f labo ra to ry te st w ere asfo llow s: a rte ria l b lood gas va lue w ith supp lem en ta l o xy-gen , pH 7 .37 , P aC o2 36 mm H g , Po , 2 00 mm H g, b ica r-bon ate 21 m EqJL , an d 02 sa tu ra tion , 99 .7% . A com ple teb lood coun t sh ow ed a h em oglob in of 12 g /dL , a hem ato -c rit o f 37% , and w hite b loo d coun t o f 7000 /L w ith anorm a l d iffe ren tia l and p late le t cou n t. A la te ra l n eck x-ray film w as ob ta in ed (F igure ) tha t show ed a m arked lysw ollen ep ig lo ttis and ary ep ig lo ttic fo lds. W hen the pa-tien t w as exam in ed in the opera ting ro om , la ryngo scop yrev ea led d iffu se edem a of th e su p rag lo ttic are a w ith voca lcords tha t appeared no rm al. A naso trach ea l tub e w asp laced w ithou t d iff icu lty . R esu lts o f flex ib le en do sco pysh ow ed circum feren tia l w hite burns a t the c ricophary n-gea l po rtion of th e esop hagus . T he b ab y w as seda ted w ithfen tany l, p aralyzed w ith pancuro n ium brom id e (Pavu -lon ) , an d dexam e thaso ne (D ecadron) and pen ic illin w erestarted.

T h e pa tien t respon ded to therapy and w as ex tu ba tedw ith in 4 8 hours . W hen la ryngo scopy an d esoph agosco pyw ere repea ted , m ild e ry them a of the ep ig lo ttis and a

http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/


3/5

F i g u r e . Lateral neck x-ray film showing markedly swol-len epiglottis and aryepiglottic folds.

1 18 P E D IA T R IC S V o l . 8 6 N o . 1 J u l y 1 99 0

persistent circumferential burn of the upper esophaguswere shown. A central line was placed and total paren-teral nutrition was started. Feedings w ith oral fluids anda soft diet were attempted 2 weeks later; however, thebaby had guaiac positive emesis and diminished oralintake w ith subsequent weight loss. A ccording to resultsof a repeat esophagoscopy, there was a narrow strictureat the level of the cricopharyngeus. A gastrostomy tubewas inserted at this time and the child cannot be fedorally and receives central hyperalimentation.

The final toxicologic analysis of the unknown liquidrevealed the follow ing: pH 12, sodium 165,000 mg/L , andpotassium 690 mg/L , values that are consistent with lyeingestion. N o controlled substances, including cocaine,were found in the remaining 15 mL of liquid. T he urinetoxic screen of the child was positive for cocaine metab-olites by the enzyme-multiplied immunoassay technique.

D I S C U S S I O NThe spectrum of child maltreatment presents

unique challenges to physicians caring for childrenin many settings. Sobel5 first called our attentionto repetitive accidental poisoning as a subtle formofchild abuse and D ine and M cgovern6 underscoredthis phenomenon in their description of intentionalpoisoning of children. M eadow7 first describedM unchausen syndrome by proxy in 1977 and sincethat time more blatant forms of child abuse havebeen described in the medical literature. In additionto these cases of aberrant behavior by caretakers,there is a range of neglect on the part of caretakersthat can result in inadequate supervision of vulner-able children. The abuse ofdrugs and alcohol withina family may accentuate the issue of neglect. A !-though the mother continued to deny recent druguse, the cocaine in the child s urine and unused lyeare highly suggestive of crack abuse. Social serviceinvestigation concluded that parental neglect wasthe factor that led to our patient s toxic ingestion.

Free-base or alkaloid cocaine is obtained by con-version and extraction of cocaine hydrochloric acidby means of kits readily available from drug para-phernalia shops. Crack is prepared by mixing streetcocaine, which is heat labile and is not suitable forsmoking, with an alkali solution such as bufferedammonia, sodium bicarbonate, baking soda, or, asin case we described, a lye solution.8 The alkaliremoves the hydrochloride salt creating the un-charged cocaine moiety. A solvent such as ether isadded and the solvent mixture is evaporated leavingrelatively pure cocaine crystals or crack that is heatstable and can be smoked. Free-base cocaine isdesirable for two reasons; it is cheaper and whensmoked it is delivered rapidly to the lung and braint o produce an immediate euphoric effect compa-rable to that of intravenous cocaine.9 The effect isshort lived and intensely habituating, however.Crack lung, a recognized complication of free-basecocaine use, includes pneumothorax, pneumome-diastinum, and pneumopericardium secondary tobarotrauma from crack inhalation. Pulmonary dif-fusion abnormalities have also been noted in abu-sers of crack.2

The half-life of cocaine metabolite in a urineassay is approximately 48 hours. This suggests thatour patient had recent exposure and the lack ofsystemic symptoms suggests low-dose exposure. A !-though this child may have been poisoned fromsidestream exposure to crack vapors, ingestion ofcocaine also must be considered as a cause. Finally,complications from the alkali used in processingcrack have not been described previously, althoughcaustic ingestions remain a signif icant cause ofpediatric morbidity. L iquid lye is responsible forthe most serious of these ingestions and may resultin esophageal burns as well as upper airway burnsw ith l ife-threatening obstructi on. #{ 176}

Esophageal burns occur rapidly by liquefactionnecrosis, and severe burns, as in this case, mayprogress to stricture formation in areas of anatomicnarrowing after 2 to 3 weeks. T reatment of causticburns to the airway and esophagus require promptstabilization of the airway, including intubation forpatients in whom signs of airway obstruction arepresent. A lthough it is controversial, many otolar-yngologists recommend treatment with steroids andantibiotics in hope of preventing stricture forma-tion.2C O N C L U S I O N

The increasing problem of drug abuse is wellknown to all of us and particularly relevant to theemergency room physician who must deal with themyriad of symptoms of acute intoxications. Chil-dren as innocent bystanders are victims of child



4/5

EXPER IENCE AND REASON 119

abuse simply by being in close proximity to illicitdrugs. Pediatricians should recognize these compli-cations and anticipate varied forms of drug inges-tions in younger patients. A ll suspicious or unclearclinical appearances should include a toxic drugscreen for medical as well as social management.

R E F E R E N C E S

SI GM UND K H ARASCH , M DROBER T V I N cI , M DROBER T REECE , M DD ept of PediatricsBos ton C ity H ospi talBoston, M A

1. Cregler LL , M aric H . M edical complications of cocainea b u s e . N EngI J M ed. 1 9 8 6; 3 1 5 : 1 4 9 5 - 1 4 9 9

2. Bates CK . M edical risks of cocaine use. W est J M ed.1 9 88 ; 1 4 8 : 4 4 0 - 4 4 4

3. Jara F, Shannon M . Cocaine-an update. C lin T oxicol R ev.1 9 88 ; 1 1 : 1 - 4

4. Bateman DA , H eagarty M C. Passive freebase cocaine( crack ) inhalation by infants and toddlers. Am J D is C hild.1989;143:25-27

5. Sobel R . The Psychological implications of A ccidental Poi-soning in C hildhood. Pediatr C lin N orth Am . 1970;17:653-6 8 5

6. D ine M S, M cGovern M E. Intentional poisoning of chil-dren-an overlooked category of child abuse: report of sevencases and review of the literature. Pediatrics. 1982;70:32-35

7. M eadow R. M unchausen syndrome by proxy: the hinterlandof child abuse. Lancet. 1977;2:343-345

8. Perez-Reyes M , Guiseppi DS, Ondrusek G , Jeffcoat A , CookC. Freebase cocaine smoking. C lin Pharm acol Ther.1 9 8 2; 3 2 : 4 5 9 - 4 6 5

9. Jekel JF, Podlewski H , Patterson SD , A llen D F, C larke N ,Cartw right P. Epidemic free-base cocaine abuse. Lan cet.1 9 86 ; 5 : 4 5 9- 4 6 2

10. M oore W R. Caustic ingestions: pathophysiology, diagnosis,a nd t rea tment. Clin Pediatr. 1986;25:192-196

11. M oulin D . U pper airway lesions in children after accidentali ngesti ons of causti c substances. J Pediatr. 1985;16:48-51

12. D icostanzo J, Noirclere M , Jouglard J, et al. N ew therapeuticapproach to corrosive burns of the upper gastrointestinaltract. G ut. 1 9 8 2; 2 1 : 2 1 8 - 2 3 7

AR T IF IC IA L L IVE R F R O M G O R TE X!

W ith the aid of a few strands of angel s hair (po!ytetrafluoroethy!ene[PTFE], Gore-Tex ), research workers in the US have created the first artificialorgan capable of functioning for more than just a few days. The organoid, anartificial liver constructed by Thompson and colleagues from hepatocytes seededon to a mixture of expanded PTFE, collagen, and heparin-binding growth factor1 (HBGF-1), has survived in the peritonea! cavity of a rat for severalmonths. . .PTFE fibres are indestructible, which makes them ideal for buildingartificial organs, as we!! as for ski and other tough clothing; they are alsobiologi cally inert...

T hompson and colleagues. . .have used this technique to implant liver cel!sfrom W istar rats (which can conjugate bilirubin) into Gunn rats (which cannot).A fter 10 days serum bilirubin levels in the host had fallen by 50%. W ithin 3weeks, levels had dropped by over 60% and remained there for the duration ofthe exper iment.REFERENCES

1. Thompson JA , H audenschild CC, A nderson KD , et al. H eparin-binding growth factor 1 inducesthe formation oforganoid neovascular structures in vivo. Proc N atlAcad Sci U SA. 1989;86:7928-7 9 3 2 .

O rganoi d adv an ces. Lancet. 1989;335:220. Noticeboard.

Noted by J.F.L ., M D



5/5

1990;86;117-119PediatricsSIGMUND KHARASCH, ROBERT VINCI and ROBERT REECE

Child Abuse?Esophagitis, Epiglottitis, and Cocaine Alkaloid ("Crack"): "Accidental" Poisoning or

& ServicesUpdated Information

http://www.pediatrics.orgincluding high-resolution figures, can be found at:

Citationshttp://www.pediatrics.org#otherarticles

This article has been cited by 3 HighWire-hosted articles:

Permissions & Licensing

http://www.pediatrics.org/misc/Permissions.shtmlits entirety can be found online at:Information about reproducing this article in parts (figures, tables) or in

Reprintshttp://www.pediatrics.org/misc/reprints.shtml

Information about ordering reprints can be found online:

http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/#otherarticleshttp://www.pediatrics.org/#otherarticleshttp://www.pediatrics.org/#otherarticleshttp://www.pediatrics.org/misc/Permissions.shtmlhttp://www.pediatrics.org/misc/Permissions.shtmlhttp://www.pediatrics.org/misc/Permissions.shtmlhttp://www.pediatrics.org/misc/reprints.shtmlhttp://www.pediatrics.org/misc/reprints.shtmlhttp://www.pediatrics.org/misc/reprints.shtmlhttp://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/http://www.pediatrics.org/misc/reprints.shtmlhttp://www.pediatrics.org/misc/Permissions.shtmlhttp://www.pediatrics.org/#otherarticleshttp://www.pediatrics.org/

cocaine alkaloids

Documents