ED visits rise for cocaine use: Don’t overlook life-threatening conditions

A patient comes to the emergency department (ED) with chest pain. Do you immediately suspect cocaine use? According to a compelling new study, you probably should. According to researchers, the number of ED patients with cardiovascular events linked to cocaine use has risen dramatically in recent years. These include angina pectoris, myocardial infarction, cardiomyopathy, and sudden death from cardiac causes.1

Current statistics underscore the prevalence of cocaine use in ED patients, warns Matthew D. Sztajnkrycer, MD, PhD, a toxicology fellow in the department of emergency medicine at the University of Cincinnati Medical Center. He points to the National Survey on Drug Use and Health, which reports that 14 million Americans are current users of illicit drugs, comprising 6.3% of the population 12 years of age or older.2 The study showed that there are 1.2 million cocaine users.

According to the Emergency Department Data from the Rockville, MD-based Drug Abuse Warning Network, which tracks drug-related ED visits across the country, there were 71 ED visits per 100,000 population for cocaine use in 2000, he adds. "To put this in perspective, heroin and marijuana both account for 39 visits per 100,000, and methamphetamine accounts for only six visits per 100,000," says Sztajnkrycer.

Here are ways to improve care of patients if you suspect cocaine use:

Don’t delay an electrocardiogram (EKG). 

If you suspect a chest pain patient is linked to cocaine use, your immediate goal should be to start treatment as quickly as possible, regardless of the cause, says Cindy Bruns, RN, BSN, CEN, quality management coordinator for the emergency center at Tallahassee (FL) Memorial Hospital.

At Tallahassee Memorial, the ED has an EKG room at triage with a dedicated technician. When anyone comes in complaining of chest pain, tightness, or pressure, an EKG is done immediately before the patient sees a triage nurse, unless the patient is in acute distress and needs to go to the treatment area immediately, explains Bruns. The technician brings every EKG to an ED physician, who reviews it and determines whether the patient can be triaged in the waiting room area or immediately brought back to the treatment area, says Bruns.

"In other words, we don’t waste time getting a history and then deciding whether or not we need to get an EKG," she says. "Even if you did get a history first, I would imagine that probably at least half the cocaine users would deny that they used cocaine." The idea is to "get the EKG first, and ask questions later," says Bruns.

While you should not delay in getting the EKG, Sztajnkrycer cautions that there are problems regarding interpretation of EKGs for cocaine-related chest pain. "There is decreased sensitivity and specificity for acute myocardial infarction compared with traditional etiology," he says. He refers to one study, which showed that although 86% of patients with cocaine-related chest pain had abnormal EKGs, only three of 48 ruled in for acute myocardial infarctions with enzymes.3

Consider clinical evidence before the patient’s history.

Red flags for possible cocaine use are ischemic changes and/or tachycardias, says Bruns. She acknowledges that age also is a factor when assessing patients for cocaine use. "While we all know that cocaine has no age boundaries, I think it’s safe to say ED nurses are more likely to ask a 29-year-old with ischemic changes on their EKG about cocaine use than a 65-year-old," she says. The clinical effects of cocaine reflect stimulation of central and peripheral adrenergic receptors, says Sztajnkrycer. They manifest as a sympathomimetic toxidrome, including mydriasis, tachycardia, hypertension, hyperthermia, and diaphoresis.

If you suspect cocaine use, you shouldn’t hesitate to use a urine drug test, says Bruns. "Ours has a turnaround time of less than an hour, and includes marijuana, cocaine, amphetamines, etc.," she says. "With the above-mentioned 29-year-old with ischemia, a urine drug test would more than likely get ordered right along with the troponin level."

Know which medications are appropriate.

According to Sztajnkrycer, the goal of treating patients with cocaine use is reducing central sympathomimetic output responsible for peripheral signs and symptoms. "Benzodiazapines are the first-line agent and should be titrated to effect," he says. However, Sztajnkrycer warns that you should avoid beta-blockers when managing cocaine-induced tachycardia and hypertension. "This may result in hypertensive emergency," he explains.

Watch out for hyperthermia in the agitated patient.

Sztajnkrycer cautions that hyperthermia is especially important to consider if the patient is restrained. Rhabdomyolysis can occur as well, with resultant acute renal failure, he adds.

Don’t assume pediatric patients haven’t used cocaine.

Obtain drug levels for children of any age if cocaine use is suspected, advises Barbara Coffel, RN, MSN, lead transport nurse at Riley Children’s Hospital in Indianapolis. If the transport team picks up a child with an unexplained change in level of consciousness, new onset seizures with no known reason, cardiac arrhythmia, or chest pain, a toxicology screening and EKG are obtained, she says. Coffel says that you shouldn’t assume that young children haven’t used drugs. "People are often reluctant to think outside the pedi box’ because we don’t want to think that kids are into bad things. The same holds true for pregnancy tests."

Obtaining early toxicology screens at least gives you a heads up as to what you might be dealing with, says Coffel. "We have had toddler-age children who have been exposed to toxic substances. One never knows what Mom and Dad keep in their desk drawer," she says. "These children needed a toxicology screen done every bit as much as they needed a head CT."

If a child presents with cardiac symptoms and no history of any cardiac issues, you should have a high index of suspicion for drug use. "Testing for drugs should be a part of a cardiac rule-out protocol," she says. "Anytime that a workup goes in the wrong direction, a potential risk is present." Because of this, Coffel recommends erring on the side of caution. "Being conservative and running tests on the outside chance that it may be the problem is better than wishing that we had," she says.

References

1. Lange RA, Hillis LD. Medical progress: Cardiovascular complications of cocaine use. N Engl J Med 2001; 345:351-358.

2. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Summary of Findings from the 2000 National Household Survey on Drug Abuse. Office of Applied Studies, NHSDA Series H-13, DHHS Publication No. (SMA) 01-3549. Rockville, MD; 2001.

3. Zimmerman JL, Dellinger RP, Majid PA. Cocaine-associated chest pain. Ann Emerg Med 1991; 20:611-615.

Sources and Resources

For more information on assessment of patients with cocaine use, contact:

Cindy Bruns, RN, BSN, CEN, Emergency Center, Tallahassee Memorial Hospital, 1300 Miccosukee Road, Tallahassee, FL 32308. Telephone: (850) 431-5079. Fax: (850) 431-6537. E-mail: bruns-c@mail.tmh.org.

Barbara Coffel, RN, MSN, Riley Hospital for Children, Clarian Health Partners, 702 Barnhill Drive, Room 1960, Indianapolis, IN 46202-5210. Telephone: (317) 274-4386. Fax: (317) 274-4354. E-mail: BCoffel@clarian.org.

Matthew D. Sztajnkrycer, MD, PhD, Toxicology Fellow, Division of Toxicology, Department of Emergency Medicine, University of Cincinnati Medical Center, 1504 Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267-0769. Telephone: (513) 558-6435. Fax: (513) 558-5791. E-mail: sztajnmd@uc.edu or sztajnkrycer.matthew@mayo.edu.

Copies of the report Summary of Findings from the 2000 National Household Survey on Drug Abuse (DHHS Publication No. SMA-01-3549) can be obtained free of charge, from the National Clearinghouse for Alcohol and Drug Information (NCADI). To order a copy, contact NCADI, P.O. Box 2345, Rockville, MD 20847-2345. Telephone: (800) 729-6686 or (301) 468-2600. Or access the report at the Substance Abuse and Mental Health Services Administration web site (www.DrugAbuseStatistics.SAMHSA.gov). Click on "Reports," "OAS Publication Series," "SAMHSA’s National Household Survey on Drug Abuse (NHSDA)," "Latest National Survey on Drug Use (NHSDA)."