Cocaine-related medical problems: consecutive series of 233 patients.

PURPOSE: Little information describing common cocaine-related medical problems is available. This study examined the nature, frequency, treatment, incidence of complications, and emergency department deaths of patients seeking medical care for acute and chronic cocaine-associated medical problems. PATIENTS AND METHODS: A consecutive series of 233 hospital visits by 216 cocaine-using patients over a 6-month period during 1986 and 1987 was studied. Medical records were retrospectively reviewed to determine patient characteristics, nature of complications, treatment, and outcome. RESULTS: Patients most commonly used cocaine intravenously (49%), but freebase or crack use was also common (23.3%). Concomitant abuse of other intoxicants, especially alcohol, was frequently seen (48.5%). The vast majority of complaints were cardiopulmonary (56.2%), neurologic (39.1%), and psychiatric (35.8%); multiple symptoms were often present (57.5%). The most common complaint was chest pain though rarely was it believed to represent ischemia. Altered mental status was common (27.4%) and ranged from psychosis to coma. Short-term pharmacologic intervention was necessary in only 24% of patients, and only 9.9% of patients were admitted. Acute mortality was less than 1%. CONCLUSION: Most medical complications of cocaine are short-lived and appear to be related to cocaine's hyperadrenergic effects. Patients usually do not require short-term therapy or hospital admission. Acute morbidity and mortality rates from cocaine use in patients presenting to the hospital are very low, suggesting that a major focus in the treatment of cocaine-related emergencies should be referral for drug abuse detoxification and treatment.

The syndrome of alcoholic ketoacidosis.

PURPOSE: To further elucidate the clinical spectrum of alcoholic ketoacidosis (AKA). PATIENTS AND METHODS: A case series of 74 patients with AKA defined as a wide anion gap metabolic acidosis unexplained by any other disorder or toxin, including any patient with a history of chronic alcohol abuse. The setting was the Medical Emergency Department at Grady Memorial Hospital in Atlanta, Georgia, a university-affiliated inner-city hospital. RESULTS: AKA is a common disorder in the emergency department, more common than previously thought. The acid-base abnormalities are more diverse than just a wide-gap metabolic acidosis and often include a concomitant metabolic alkalosis, hyperchloremic acidosis, or respiratory alkalosis. Lactic acidosis is also common. Semiquantitative serum acetoacetate levels were positive in 96% of patients. Elevated blood alcohol levels were present in two thirds of patients in whom alcohol levels were determined, and levels consistent with intoxication were seen in 40% of these patients. Electrolyte disorders including hyponatremia, hypokalemia, hypophosphatemia, hyperglycemia, hypocalcemia, and hypomagnesemia were common on presentation. The most common symptoms were nausea, vomiting, and abdominal pain. The most common physical findings were tachycardia, tachypnea, and abdominal tenderness. Altered mental status, fever, hypothermia, or other abnormal findings were uncommon and reflected other underlying processes. CONCLUSIONS: AKA is a common disorder in chronic malnourished alcoholic persons. The acid-base abnormalities reflect not only the ketoacidosis, but also associated extracellular fluid volume depletion, alcohol withdrawal, pain, sepsis, or severe liver disease. Although the pathophysiology is complex, the syndrome is rapidly reversible and has a low mortality.

Drinking on campus. Undergraduate intoxication requiring emergency care.

OBJECTIVES: To (1) determine the incidence of undergraduate graduate students with alcohol intoxication who presented to our emergency department (ED), (2) examine the demographic correlates of the students, and (3) look at associated injuries that were sustained by the students. DESIGN: Retrospective case series. SETTING: A tertiary care medical center that was located on the campus of a major university. PATIENTS: Undergraduate students with alcohol intoxication who presented to the ED. MAIN OUTCOME MEASURES: Demographic data and associated injuries of intoxicated students who presented to the ED during 2 academic years. RESULTS: Forty-four students presented with alcohol intoxication for a yearly incidence of 3.9 per 1000 students. Freshmen were overrepresented compared with students in other higher classes, with an incidence of 9.3 per 1000 per year (P < .001). Nine (20%) of the 44 students sustained an injury from a fall, and 1 required mechanical ventilation for treatment of apnea. CONCLUSIONS: Alcohol intoxication that requires emergency care is not uncommon among college students, and many students with alcohol intoxication present to the ED following a fall. Freshmen are particularly likely to present for care in an ED.

Lidocaine in the treatment of status epilepticus.

Intravenous lidocaine has the potential to control seizures. This article reviews the available evidence related to lidocaine's efficacy and clarifies its potential role in the management of status epilepticus (SE). Although there are no large, double-blind, placebo-controlled studies of lidocaine's efficacy in SE, numerous case reports and case series support its use. Most of the reported cases involve patients who were refractory to multiple antiseizure medications. Additional support for lidocaine's efficacy in SE comes from the pediatric literature, where lidocaine has been very effective in controlling SE in neonates who have not responded to barbiturates. Initial lidocaine doses used to stop seizures have ranged from 1 to 3 mg/kg. Most reports recommend a maintenance infusion of lidocaine after initial termination of SE, and a continuous infusion is almost universally recommended for neonates. Toxicity from a 1.5-2.0 mg/kg dose of lidocaine for the control of SE is rare; the authors found only 1 case of a possible side effect at that dose. The article provides a 5-step approach to treating SE that includes lidocaine.

Emergency department evaluation of the chest pain patient.

The emergency physician must have a high degree of suspicion for myocardial ischemia in patients presenting with no obvious for their chest pain. The role of the emergency physician is to determine a relative risk for each patient and to order the appropriate studies to minimize the risk of missed myocardial infarction as well as to recognize acute ischemia or infarction and manage it aggressively. It is not possible to rule out myocardial ischemia or infarction subjectively. It is the opinion of these authors that some form of further testing should be performed on patients in all categories, except those determined to be at very low risk.

Neurologic complications of alcoholism.

Neurologic and myopathic complications of alcoholism are multiple and diverse, affecting both the central and peripheral nervous systems. In the ED, initial concern is for diagnosing readily reversible causes and ruling out possible life- or limb-threatening etiologies. A rapid assessment of the ABCs, a fingerstick blood glucose determination, and, in cases of AMS, the administration of intravenous naloxone is indicated. In almost every instance of a potential neurologic complication, intravenous thiamine replacement is indicated initially, along with the parenteral administration of folic acid and the other B vitamins, including nicotinic acid and pyridoxine. Metabolic screening with electrolytes, glucose, blood urea nitrogen, creatinine, calcium, magnesium, liver enzymes (AST, alkaline phosphatase), bilirubin, arterial blood gases with carboxyhemoglobin determination, and a complete blood count are often warranted. Special tests such as CT scan, CK, ammonia, or toxicologic screens are indicated in specific instances. In terms of physical examination, attention to the presence of focal neurologic findings is paramount because of the possibility of a subdural or epidural hematoma. It is important not to miss meningitis and a low threshold for treatment or lumbar puncture should be maintained. Specialized consultation and referral are needed only after stabilization and appropriate tests are performed. If an organized approach to the evaluation of an alcoholic with neurologic symptoms is undertaken, occult disease will not be missed and outcomes will be improved.

Endocarditis in intravenous drug abusers.

IE due to parenteral drug use is an ever-increasing problem for physicians working in the ED. IE may present with a multitude of signs and symptoms of variable severity. Patients may complain of only vague symptoms consistent with a viral syndrome, or they may present with a neurologic or cardiovascular catastrophe. ED physicians must have a high degree of suspicion for IE whenever they evaluate a patient who could possibly be abusing drugs.

Tight-fitting garments as counterpressure devices.

A case of traumatic splenic rupture in a hemodynamically stable elderly woman is presented. The patient decompensated almost immediately following the removal of a tight-fitting girdle. The implications of recognizing garments as potential counterpressure devices in emergency management are discussed. Emergency physicians are cautioned to carefully explore and reevaluate patients after the removal of tight-fitting garments.

Sudden respiratory deterioration in the positive pressure ventilated patient: an organized approach to diagnosis and therapy.

A case of sudden deterioration in the respiratory status of a 28-year-old man being manually ventilated is presented. The patient's deterioration was presumed to be secondary to malfunction of the expiratory valve of the Ambu bag. The resulting high pressure generated in the system caused the patient to develop a bilateral pneumothorax, pneumomediastinum, and displacement of the endotracheal tube into the oropharynx. An organized approach to the diagnosis and treatment of the rapid deterioration in the respiratory status of a manually ventilated patient is presented.

"Occult" Boerhaave's syndrome.

Spontaneous rupture of the esophagus (Boerhaave's syndrome) usually presents in a dramatic fashion. Classically, following repeated episodes of vomiting, patients present with chest pain, dyspnea, cyanosis, shock, and cardiovascular collapse. We present a case of occult Boerhaave's syndrome diagnosed by an upper gastrointestinal series in a 33-year-old man who arrived at the emergency department with a chief complaint of hematemesis. This case report reviews the usual presenting signs and symptoms of Boerhaave's syndrome and concludes with a caution to physicians not to ignore the possibility of this disease entity in relatively stable patients.

Feedback to emergency medical services providers: the good, the bad, and the ignored.

HYPOTHESIS: To determine the type and frequency of immediate unsolicited feedback received by emergency medical service (EMS) providers from patients or their family members and emergency department (ED) personnel. METHODS: Prospective, observational study of 69 emergency medical services providers in an urban emergency medical service system and 12 metropolitan emergency departments. Feedback was rated by two medical student observers using a prospectively devised original scale. RESULTS: In 295 encounters with patients or family, feedback was rated as follows: 1) none in 224 (76%); 2) positive in 51 (17%); 3) negative in 19 (6%); and 4) mixed in one (< 1%). Feedback from 254 encounters with emergency department personnel was rated as: 1) none in 185 (73%); 2) positive in 46 (18%); 3) negative in 21 (8%); and 4) mixed in 2 (1%). Patients who had consumed alcohol were more likely to give negative feedback than were patients who had not consumed alcohol. Feedback from emergency department personnel occurred more often when the emergency medical service provider considered the patient to be critically ill. CONCLUSIONS: The two groups provided feedback to emergency medical service providers in approximately one quarter of the calls. When feedback was provided, it was positive more than twice as often as it was negative. Emergency physicians should give regular and constructive feedback to emergency medical services providers more often than currently is the case.

Self-reported cardiac risk factors in emergency department nurses and paramedics.

STUDY OBJECTIVE: Our objective was to assess the prevalence of cardiac risk factors in a sample of urban paramedics and emergency department (ED) nurses. METHODS: We asked 175 paramedics and ED nurses working at a busy, urban ED to complete a cardiovascular risk assessment. The survey asked subjects to report smoking history, diet, exercise habits, weight, stress levels, medication use, history of hypertension or cardiac disease, family history of cardiovascular disease (CVD), and cholesterol level (if known). RESULTS: 129 of 175 surveys were returned (74% return rate) by 85 paramedics and 44 nurses. The percentages of paramedics and nurses at high or very high risk for cardiac disease were 48% and 41%, respectively. Forty-one percent of female respondents and 46% of male respondents were at high or very high risk. Cigarette smoking was reported in 19% of the paramedics and 14% of the nurses. The percentages of paramedics and nurses who reported hypertension were 13% and 11%, respectively. High cholesterol was reported in 31% of paramedics and 16% of nurses. CONCLUSIONS: Forty-eight percent of paramedics and 41% of ED nurses at this center are at high or very high risk for cardiovascular disease, by self-report. Efforts should be made to better educate and intervene in this population of health-care providers in order to reduce their cardiac risk.

Spontaneous drainage of cardiac tamponade.

The case of a 23-year-old man with life-threatening pericardial tamponade resulting from a cardiac stab wound is presented. After initial attempts at stabilization failed to reverse the progressively worsening status of the patient, he was prepared for surgery. Just prior to induction of anesthesia, blood began to flow from the patient's chest tube, resulting in a return to a near normal hemodynamic status. This was believed to be the result of spontaneous drainage of cardiac tamponade prior to cardiorrhaphy. The patient was discharged ten days post admission in excellent health and was doing well at a one-month follow-up visit. The discussion includes what comprises definitive care for cardiac tamponade, and the controversy in the timing and appropriateness of pericardiocentesis.

Severe metabolic alkalosis in the emergency department.

A case of severe metabolic alkalosis (MA) resulting from ingestion of baking soda (sodium bicarbonate) is presented. On admission to the emergency department, the patient was alert and stable with an initial examination that was remarkable only for carpopedal spasm. Shortly thereafter, the patient had a sudden, unexpected cardiopulmonary arrest. Following resuscitation, without administration of sodium bicarbonate, the arterial blood gas revealed a pH of 7.73, pO2 of 51 mm Hg, and pCO2 of 52 mm Hg. After admission to the intensive care unit, the patient's MA was corrected using IV 0.25 N hydrochloric acid. The patient remained comatose as a result of severe anoxic encephalopathy and died two weeks after admission. We believe this is the first reported case of severe MA resulting in sudden cardiopulmonary arrest in a previously ambulatory patient.

Hypophosphatemia in the emergency department therapeutics.

Although hypophosphatemia is relatively uncommon, it may be seen in anywhere from 20% to 80% of patients who present to the ED with alcoholic emergencies, diabetic ketoacidosis (DKA), and sepsis. Severe hypophosphatemia, as defined by a serum level below 1.0 mg/dL, may cause acute respiratory failure, myocardial depression, or seizures. Because hypophosphatemia is not as often treated by ED physicians, becoming familiar with a single intravenous phosphate solution and specific guidelines for phosphate repletion are essential. One mL of the most commonly available phosphate solution (K2PO4) contains 4.4 meq of potassium and 3 mmol (93 mgs) of phosphate. Administering K2PO4 at a rate of 1 mL per hour is almost always a very safe and appropriate treatment for hypophosphatemia. This article provides guidelines for phosphate therapy in hypophosphatemic ED patients including those in DKA, those presenting with alcohol-related complaints including alcoholic ketoacidosis and patients with acute exacerbation of asthma and chronic obstructive pulmonary disease.

The technique of reversing ventricular fibrillation: improve the odds of success with this five-phase approach.

Early, repeated defibrillation is the key to managing ventricular fibrillation (VF). To maximize the likelihood of success, use this five-phase approach, modified from the advanced cardiac life support protocols. Phase I: When a patient is found in VF and with no pulse or signs of life, attempt electrical reversion with a 200-wsec shock, followed if necessary by a 300-wsec and a 360-wsec shock. Phase II: Manage reversible causes of VF with orotracheal intubation, hyperventilation, and epinephrine. Phase III: Use intravenous lidocaine aggressively, followed by a 360-wsec shock. Phase IV: Give bretylium and magnesium sulfate by intravenous push, again followed by a 360-wsec shock. Phase V: Treat refractory VF with repeated 360-wsec shocks, and give further doses of the anti-arrhythmic agents.