cocaine track d september 17, 2003 barcelona lewis r. goldfrank, md professor and chairman of...
TRANSCRIPT
Cocaine
Track D
September 17, 2003
Barcelona
Lewis R. Goldfrank, MDProfessor and Chairman of Emergency Medicine
New York University Medical Center Bellevue Hospital Center
New York University School of MedicineMedical Director, New York City Poison Center
Case 1
A twenty year old man is brought to the ED by ten New York City police in a body bag. He is uncontrollably agitated. He is diffusely diaphoretic with RR 24, HR 160, BP160/120. What should be done?
Physical wet packs, restraining chairs
nets, straight jackets, restraints
Chemical bromides, antihistamines, morphine
paraldehyde, chloral hydrate, ethanol
antipsychotics: phenothiazines/butyrophenones
barbiturates
benzodiazepines: diazepam, oxazepam, lorazepam, midazolam
-Adrenergic antagonists, a2 adrenergic agonists
History
Therapeutic Interventions for the Agitated Patient
Physical restraints only serve to temporize, while awaiting chemical restraints.
Struggle against physical restraints may lead to fatal hyperthermic events
Avoid vinyl “body-bags”
Avoid cervical collars when not indicated
Mesh or netting restraints work
Use restraining devices that
Will allow for heat dissipation
Control the Situation
Control the Situation
Do not attempt to restrain an agitated patient until you have them thoroughly outnumbered
A. Limits the risk of harm to yourself
B. Rapidly controls the patient in order to minimize the risk of patient trauma
Control the Situation
Proper restraint requires at least five to six rescuers
A. One person handles each extremity
B. One person manages the head and airway
C. One person coordinates the activity
D. Universal precautions should be utilized
at all times
One hand just proximal and one hand just distal to the joint
Immobilize both elbows and knees in extension
Restricts movement.
Team leader secures the patient’s head by grasping the forehead with one hand and securing the chin with the other.
Check each limb for discoloration and any compromise of pulse and capillary refill.
Must be able to place two fingers under the restraint.
Patient’s face, mouth, and neck must not be covered or restrained.
Control the Situation
Begin the cooling process
A. Remove all clothing
B. Volume resuscitate to allow for sweating
C. Cool the skin with ice bath.
Agitated Delirium
(Life-threats)
Hyperthermia
Volume depletion
Rhabdomyolysis
Seizures
CNS Agitation
Increased Neuronal Firing
Reuptake Blockade
Exaggerated Sympathetic Response
Model for Cocaine Toxicity
Seizures Hyperthermia
Cardiovascular complications
Control the Situation
Struggling increases catecholamine release which can exacerbate cocaine toxicity
Prolonged struggling or chasing increases heat production
Hyperthermia is one of the best prognosticators for lethal cocaine events
Agitated Delirium
(Treatment)
Rapid Cooling
Volume resuscitation
Sedation
Control the Situation
Give good general care for seriously ill patients
A. IV dextrose and thiamine
B. Avoid naloxone
C. Oxygen and cardiac monitor
Control the Situation
Stop the heat production – use
chemical sedation
A. Benzodiazepines are preferred
B. Barbiturates are a good second choice
C. Avoid all antipsychotics
Agitated Delirium
(Treatment)
Choice of Sedatives
1. IV always preferred 2. If IM is required
Midazolam Midazolam
Lorazepam Lorazepam
Diazepam Sodium Amytal
Barbiturates
Consequential Complications
Benzodiazepines Butyrophenones
Sedation
excessive Prolonged Respiratory
depression
Delay to sedation
extrapyramidal reactions (dystonia)
torsades de pointes
thermoregulatory disorders
neuroleptic malignant syndrome
Six Good Reasons to Avoid Phenothiazines and Butyrophenones
Lower seizure threshold
Interfere with heal dissipation
Exacerbate tachycardia
Produce hypotension
Increase heat production (movement disorders)
Not cross-tolerant with ethanol and other sedative hypnotics
Ability of Propranolol to Modify Cocaine Toxicity
Drug BP Pulse pH Temp Seizures Death
Cocaine
Propranolol N N
Catravas et al: J Pharm Exp Ther 217:315,1961.
Guinn et al: Clin Tox 16:499,1980.
Agitated Delirium(Pitfalls)
Use of Beta adrenergic antagonists
Use of Mixed Alpha-Beta adrenergic antagonists
Failure to Aggressively Cool
Use of Dantrolene