Coccain and Sympathomimatic

Cocaine and Other SympathomimeticsCocaine and Other Sympathomimetics

Muzna al sawwafi

Emergency medicine/R1

Pathophysiology:

Acute cocaine use causes release of dopamine, epinephrine, norepinephrine, and serotonie.

Sodium blocker: analgesic effect,(acts similar to class 1A antidysrhythmic drugs.

Cocaine is a local anathetic agent throughCocaine is a local anathetic agent through::

*releaseing of norepinephrine,

*releasing of dopamine,

*blocking Na cahnnels

Clinical Effects of Sympathomimetics:

Hypertension

Tachycardia

Mydriasis

Diaphoresis

Hyperthermia

Central nervous system excitation

Cocaine Formulations:

crack cocaine,

cocaine hydrochloride and cocaine sulfate.

CLINICAL FEATURES:Moderate,

Sever, +/- Signs and symptoms of end-organ damage; this includes acute hypertensive

emergencies .focal, acute pain syndromes, circulatory abnormalities, delirium, or seizures.

Speedballing

Complications:hyperthermia, hypertensive emergencies, and cardiac dysrhythmias(sinus tachy.)

Hyperthermia,

Hypertensive Emergencies:CVS and CNS:Reported sequelae include aortic dissection,pulmonary edema, myocardial ischemia and infarction,ICH, strokes, and

infarction of the anterior spinal artery .

Locally induced HTN and vasospasm:

Intestinal infarctions and mesenteric ischemia (body packers with large oral

ingestions) .

Other local ischemic events include retinal vasospasm, renal infarctions, and placental insufficiency and infarction in the gravid uterus.

Other Complications:

crack dancing,

DVT,

Paranoia,

Inhalation of crack cocaine,

Pneumothorax, pneumopericardium, and pneumomediastinum(barotrauma),

Intranasal use: nasal perforation and sinusitis.

IV users: endocarditis, risk of infection with blood-borne viruses.

Regarding cocaine metabolism, Regarding cocaine metabolism, true/falsetrue/false::

*cocaine metabolite in the liver and kidney*norcocaine is produced by the liver

*benzoyl ecgonine detected in urine screen is helpful for the management of acute intoxication

benzoyl ecgonine, beneficial to : (1) document possible abuse or neglect in a child with suspected exposure, (2) confirm cocaine as the unknown substance in body packers, and (3) differentiate paranoia into drug-induced or psychiatric causes.

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ECG,CK, CK-MB, TROP,.

CT/LP(SEVER HEADCHE).

Least likely ECG to be seen in sever cocaine toxicity:

AA

BB

CC

DD

EE

Differential Diagnosis of Agitated Delirium:

Metabolic causes, Structural lesions of the CNS ,

Endocrine disease, Infections, Toxicologic causes, Heatstroke, Postictal.

Initial Evaluation of Patients with Sympathetic Stimulation:

Rapid assessment of vital signs, especially core temperature

Rule out hypoxia, hypoglycemia

Pharmacologic sedation with benzodiazepines

Electrocardiogram

Urinalysis

Serum creatinine phosphokinase

Pharmacologic Sedation

IV diazepam,

Hyperthermia: rapid cooling,

What is the anti-HTN drug off choice for What is the anti-HTN drug off choice for Hypertensive Emergencies in cocaine Hypertensive Emergencies in cocaine overdoseoverdose??

Phentolamine, a direct alpha-adrenergic antagonist, is the antihypertensive of choice.

Regarding the managment of Regarding the managment of dysrhythmias in cocaine toxicity all false dysrhythmias in cocaine toxicity all false exceptexcept::

*always respond to sedation with benzodiazepines.

*may consider beta antagonist ,*for a wide-complex tachycardia start with

benzodiazepines, sodium bicarbonate,and Lidocaine to have a rapid reverse of dysrythemia

*Lidocaine increases seizure risk and mortality

Cocaine-Related Chest Pain:found significant angiographic stenosis in individuals with positive serum enzyme markers for myocardial infarction.

benzodiazepine administration decreases myocardial oxygen demand by limiting peripheral stimulation.

Treat as non—cocaine-induced myocardial infarction.

Treatment of asymptomatic patients should Treatment of asymptomatic patients should include all the following include all the following exceptexcept::

*laxatives (eg, sodium sulfate, magnesium sulfate, magnesium citrate),

*paraffin-containing laxatives (eg, Lansoyl)

*whole-bowel irrigation ,

*several doses of activated charcoal ,

*close observation

Cocaine Body Packers:Single absolute indication for surgical intervention:

pt is symptomatic.

observed until all packets have passed:

three packet-free stools, a reliable packet count consistent with the ingestion, and a negative contrast radiographic study.

AmphetaminesAmphetamines::

True/false:

*enhance release of catecholamines from presynaptic nerve terminals ,

*block sodium channels,

*don’t affect presynaptic reuptake of catecholamines.

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Choose the correct matchingChoose the correct matching::

*MDMA (Ecstasy, XTC, Adam)……smokable

*Ephedra……. all-night dance parties

*Methamphetamine…..metals intoxication

*Khat……. excessive sympathomimetic stimulation

Which of the following can be associated Which of the following can be associated with life threatning hyponatremiawith life threatning hyponatremia??

*MDMA

*Ephedra

*Methamphetamine

*methacathinone

AnticholinergicsAnticholinergics

Three main groups:

Antimuscarinics, affecting the muscarinic acetylcholine receptors;

Neuromuscular blockers, blocking nicotinic acetylcholine receptors ,

Ganglionic blockers, affecting acetylcholine sympathetic and parasympathetic nicotinic ganglia..

Medical usageMedical usage::

pupillary dilators (atropine, homatropine, tropicamide, cyclopentolate),

antispasmodics (dicyclomine),

decrease gastric secretions (propantheline), prevent motion sickness (scopolamine),

treat asthma (ipratropium),

bradycardia (atropine).

Atropine or scopolamine is used to dry airway secretions and block vagal responses to

laryngoscopy and endotracheal intubation .

Drugs Exhibiting Primarily Anticholinergic Toxicity:

Belladonna Alkaloids, Antiparkinson, H1-Receptor Blockers , Phenothiazine.

Drugs Exhibiting Anticholinergic Effects as Part of Toxic Manifestations:

TCA, Phenothiazines.

Which of the following phenothiazines has Which of the following phenothiazines has a Primarily Anticholinergic Toxicitya Primarily Anticholinergic Toxicity??

Chlorpromazine

Prochlorperazine

Promethazine

Mesoridazine

Thioridazine

Two likely settings for anticholinergic over Two likely settings for anticholinergic over dosedose::

) 1 (the elderly patient taking anticholinergic drugs for parkinsonism or another chronic disease,

)2 (the psychiatric patient receiving neuroleptic therapy and an anticholinergic or tricyclic antidepressant

Manifestations of the antimuscarinic syndrome:

tachycardia, pupillary dilation, loss of accommodation, inability to sweat, drying of mucosal surfaces, gastrointestinal paralysis,

and urinary retention .

In the CNS: seizures, coma, choreoathetosis, memory impairment, and perceptual and cognitive dysfunction.

Least sensitive organs to antimuscurinicLeast sensitive organs to antimuscurinic::

Salivary/sweat glands+lungs

Eyes+bladder,

CNS+GI

Eyes+heart +cns,

Bladder+GI,

Why hyperthermiaWhy hyperthermia??

The hyperthermic patient may develop hepatic necrosis, rhabdomyolysis with myoglobinuric renal failure, cerebral edema, and disseminated intravascular coagulation with hemorrhage

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS::

Toxic, Metabolic, Infectious/Inflammatory, Neurologic/Neurosurgical.

So, how to diffrentiate between anticholinergic and:

Sympathommetic?

Phencyclidine?

Neuroleptic malignant syndrome?

DIAGNOSTIC STRATEGIES

serum electrolytes, renal function, creatinine phosphokinase level, and glucose level. Arterial blood gas,

Comatose patient: 50% dextrose, thiamine, oxygen, and naloxone,

Consider common co-ingestant

LP/CT.

MANAGEMENTMANAGEMENT::Agitation,Benzodiazepines?

hypotension is unlikely, the possibility of seizures is decreased,& anticholinergic effects

are absent . Hyperthermia,Seizures, Decontamination:

No evidence for the role of activated charcoal/gastric lavage,

PhysostigminePhysostigmine,

Mechanism of action?

Its role in the management of anticholinergic overdoses has been controversial.

Reveres both agitation(96%) and delirium(87%),

Two CI?

Administiration?

DispositionDisposition::hyperthermia, agitation, coma, or seizures: ICU,

asymptomatic patient :4 hours of observation. Patients who have ingested Datura stramonium seeds or cyclobenzaprine should be observed for 8 hours.

Predischarge measuresPredischarge measures::psychiatric assessment, documentation of a nontoxic acetaminophen level, and assessment

of a child's home situation ..