mediccjh Posted May 30, 2006 Share Posted May 30, 2006 First off, a speedball is also cocaine and heroin. He was dumb enough to take cocaine, he can walk. If you are gonna treat him, treat him with Valium or any other benzo. ASA and NTG will not work on CP due to cocaine. Something to do w/ the adrenergic rush from the coke. Link to comment Share on other sites More sharing options...
AZCEP Posted May 30, 2006 Share Posted May 30, 2006 NTG will work for this individual, as the chest pain that occurs following cocaine use is related more to vasospasm than to vascular occlusion by a thrombus. ASA is also still indicated for the possibility of a clot forming in the stenotic vessels. Valium is a good call for the sympathomimetic toxidrome. Beta blockers would be a bad idea in most situations like this one, simply by leaving the alpha effects unopposed. Link to comment Share on other sites More sharing options...
chbare Posted May 30, 2006 Share Posted May 30, 2006 AZCEP, I agree with the use of ASA and Nitro. Nitro has been used with success to counteract cocaine induced vasoconstriction. I believe an alpha blocker such as phentolamine is the next choice for treatment if Nitro and judicious use of benzos do not help. I would consider beta blockers if the primary treatments fail. I think the use of a selective B1 blocker such as esmolol may be considered as a last line drug. Take care, chbare. Link to comment Share on other sites More sharing options...
ERDoc Posted May 30, 2006 Author Share Posted May 30, 2006 There is no tenderness/pain is not reproducable. The pt was chatting with some friends about the theory of relativity and its relationship to the season finale of Grey's Anatomy. This is his first time speedballing. So it sounds like everyone wants to see a 12-lead, so here it is. Link to comment Share on other sites More sharing options...
ERDoc Posted May 30, 2006 Author Share Posted May 30, 2006 It sounds as if everyone is in agreement on ntg (although you would need to watch out for reflex tachycardia). ASA is not a bad idea, won't hurt in most cases. Someone mentioned beta-blockade for BP. This would be BAD. Cocaine is an alpha agonist. If you block just the beta receptors you have unopposed alpha activity, which causes vasoconstriction, worsening the already bad MI, increasing the BP and possibly leading to stroke. This is the one MI where you NEVER give beta-blockers. You can start with something like labetalol which has both alpha and beta, or you can go with other options. This guy is having a cocaine induced MI, which is not all that uncommon. Link to comment Share on other sites More sharing options...
JPINFV Posted May 30, 2006 Share Posted May 30, 2006 Isn't the exception to "no beta blockers in this case" people who watch Grey's Anatomy (or The OC, but that is a local bias...)? Link to comment Share on other sites More sharing options...
chbare Posted May 30, 2006 Share Posted May 30, 2006 I agree, everybody is correct, beta blockers will cause more harm than good. Uncontrolled alpha stimulation and worsened vessel spasm leading to worsened ischemia and damage. The esmolol thing would be more of an act of desperation, and I do not think we are even close to that point with this patient. In addition I believe the esmolol would be given with nitroprusside. Sorry about that. Take care, chbare. Link to comment Share on other sites More sharing options...
sfrme Posted May 30, 2006 Share Posted May 30, 2006 MONA (minus the Morphine), IV TKO (as not to increase B/P, but to dilute any non-absorbed substances in the blood) Monitor rhythm for disturbances. Prepare Lido as needed. Ok, I'm still a student, so a question for the vets - Can you use Diazepam (for Cocaine) and Narcan (for Heroin) together? Have multiple doses of Narcan ready, as some Heroin lasts longer than the Narcan. Have your intubation kit open and ready. ? genetic hx of MI - predisposed to something that the speed-balling aggravated Contact Med Control/Poison Center - And as always FOLLOW LOCAL PROTOCOLS Link to comment Share on other sites More sharing options...
ERDoc Posted May 30, 2006 Author Share Posted May 30, 2006 Here is a link to a great article on cocaine toxicology from emedicine: http://www.emedicine.com/emerg/topic102.htm I stand corrected as to one of my previous posts. Labetalol has a 1:7 ratio of activity on alpha:beta receptors, so it is not the best choice. Looks like we all learn something from these scenarios. Link to comment Share on other sites More sharing options...
chbare Posted May 30, 2006 Share Posted May 30, 2006 ERDoc, thanks again for your scenarios. They definitely require critical thinking and spark good conversation. Take care, chbare. Link to comment Share on other sites More sharing options...
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