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Cocaine intoxication, delirium, death in body packer
Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACEP, or UAEM
CORRESPONDENCE Thrombolytic Therapy for Effort Thrombosis of Subclavian Vein? To the Editor: I read with interest a case report on Effort Thrombosis of the Subclavian Vein reported recently in Annals (10:596599, November 1981). Options for care of this disease, as discussed in the article, range from heparinization to surgery. I would suggest that there might be a role for use of thrombolytic therapy with either streptokinase or urokinase, and I would like to ask the authors of this case report if they considered this treat-
ment modality and if they are aware of reports of the use of thrombolytic therapy for this type of problem.
Dan K. Morhaim, MD, Director Department of Emergency Medicine Franklin Square Hospital Baltimore
Author's Reply Yes, we are aware of the use of thrombolytic therapy in the treatment of this disorder. However, in view of the relationship between birth control medication and its effects on antithrombin III levels, we elected to use heparin as the
therapeutic modality.
James R. Sowers, MD VA Medical Center, Sepulveda, California
Oxygen for All Asthmatics on Bronchodilators To the Editor: Martin and coworkers conclude in a recent article ("Use of Peak Expiratory Flow Rates to Eliminate Unnecessary Arterial Blood Gases in Acute Asthma," 11:70-73, February 1982) that PEFR (peak expiratory flow rate) could be used as a tool to decide if ABGs are necessary. Unfortunately they conclude their article with a less-than-vigorous stand by stating that "supplemental oxygen should be considered in all asthmatic patients." The acute asthmatic patient who is in need of bronchodilation has demonstrated an increased pulmonary blood flow out of proportion to the bronchodilation in poorly ventilated areas, thus worsening the already-present ventilation perfusion mismatch (Va/Q) and decreasing PaO2. In those with a low PaO2, a small drop can be dangerous by shifting the oxyhemoglobin dissociation curve toward the steep slope, reducing the amount of oxygen saturation and increasing pulmonary artery pressure with its concomitant
afterload effect on the right ventricle. This decrease in PaO2 can follow a functionally significant improvement in PEFR, so that the patient may obtain relief of his bronchospasm despite a low PaO2.1 Therefore, all asthmatic patients receiving bronchodilators (epinephrine, aminophylline, terbutaline, etc) should receive appropriate amounts of oxygen, whether or not an ABG is necessary.
Donald Forester, MD, Chief Section on Emergency Medicine The Mount Vernon Hospital Mount Vernon, N e w York 1. Flenley DC: Blood gas abnormalities and acute respiratory failure, in Stein M (ed): New Directions in Asthma. American College of Chest Physicians, 1975, pp 495-522.
Author's Reply I call Dr. Forester's attention to the very last sentence in our article: "Because hypoxia is unpredictable both upon presentation and following treatment, supplemental oxygen should be considered in all asthmatic patients." This is the
same point Dr. Forester is making.
Thomas G. Martin, MD Portland, Oregon
Cocaine Intoxication, Delirium, Death In Body Packer To the Editor: The report by Fishbain and Wetli on cocaine intoxication in a body packer (10:531-532, October 1981) is indeed interesting. The clinical presentation of polydipsia, agitation, altered mental status, tachycardia, and increased respiratory rate are not necessarily signs and symptoms of cocaine toxicity. Other disease processes should be considered. The gradual 70/389
deterioration in the patient's mental status indicated at least blood glucose, venous or arterial pH and serum electrolyte determinatiOns. Intravenous administration of naloxone and 50% glucose solution would have been appropriate initial therapy pending laboratory results. An abdominal film did not reveal foreign bodies, but the patient's statement that he swallowed an aluminum foil
Annals of Emergency Medicine
11:7 July 1982
packet of cocaine is accepted. Aluminum is a highly radioopaque metal, and failure to demonstrate this radio-opacity may simply be that the patient is not telling the truth. Another cause for his illness should have been sought, and the patient managed as a potential unknown overdose. It is not uncommon to encounter a violent, unpleasant patient in the emergency department. It is our role as emergency physicians to deal with such patients. The easiest and wrong approach is to label the patient with a diagnosis and transfer him to a remote observation or psychiatric unit without having a clear assessment and some understanding as to the nature of the disease process. It is obvious that the diagnosis of cocaine overdose was never documented by a toxicology screen. A medical diagnosis cannot be based on a police investigation and indirect evidence. Haldol, in our experience, is very effective in managing a violent patient. Sodium amytal may be helpful, provided that the patient is carefully monitored. Respiratory arrest is not usually sudden in onset. Preced-
ing signs and symptoms were probably not monitored and, therefore, other causes of respiratory arrest (eg, cardiac arrhythmia) cannot be excluded. Autopsy findings were pulmonary edema and cerebral edema (probably from long-standing hypoxia). Whether this was a consequence of Cocaine overdose, opiate overdose (in spite of the initial mydriasis), neurogenic pulmonary edema, or something else cannot be ascertained from the work up presented. Given the unreliability of the patient's history, emergency toxicology screens of both urine and blood were clearly indicated in this case.
David Bar-Or, MD Denver General Hospital Emergency Medicine Service Linda Wahby, MD St. Joseph Hospital St. Anthony Hospital Emergency Medicine Service Denver
Author's Reply The patient's change in mental status was not perceived as "deteriorating" because the patientbecame more agitated rather than sedated. The focus of the paper was therefore the recognition of delirium. Steps suggested by Dr. Bar-Or would be appropriate if such recognition could be achieved. Dr. Bar-Or suggests that the patient should have been treated as an "unknown overdose." This decision again depends on the perception by the emergency physician that the change in mental status of the patient is secondary to organic factors. Cause of death was unknown until determined by the medical examiner. This determination was based on the following: 1) ruptured finger cot of cocaine found in the cecum; 2) police investigation labelling the victim as a "body packer"; and 3) blood cocaine levels of .21 mg/LJ (This was not reported in the original paper.) The most widely accepted form of treatment for most drug-induced delirium is haloperidol; 2 however, haloperidol may make an atropine-like delirium worse. It may, therefore, become necessary where the type of delirium is unknown to simply sedate and observe the patient) Sodium amytal and Valium ® could be used for this purpose.
11:7 July 1982
The final cause of death could have been a cardiac arrhythmia. This information is not available, as the final monitoring was done in a psychiatric holding area. This monitoring is usually not very stringent because it is taken for granted that patients referred from medical emergency departments are !'medically clear." "Toxicology screens" are clearly indicated in patients in whom the delirium is of unknown etiology, or when there is an unreliable history.
David A. Fishbain, MD, Director Psychiatric Emergency Services Mental Health Services Division University of Miami School of Medicine Miami 1. Wetli CV, Mettleman RE: The "body packer syndrome": Toxicity following ingestion of illicit drugs packaged for transportation. Forensic Sci 26:492-5000, 1981. 2. Disdafani A, Hall RC, Gardner ERi Drug-induced psychosis: Emergency diagnosis and management. Psychosomatics 22:845855, 1981.
Annals of Emergency Medicine
390/71
CORRESPONDENCE Thrombolytic Therapy for Effort Thrombosis of Subclavian Vein? To the Editor: I read with interest a case report on Effort Thrombosis of the Subclavian Vein reported recently in Annals (10:596599, November 1981). Options for care of this disease, as discussed in the article, range from heparinization to surgery. I would suggest that there might be a role for use of thrombolytic therapy with either streptokinase or urokinase, and I would like to ask the authors of this case report if they considered this treat-
ment modality and if they are aware of reports of the use of thrombolytic therapy for this type of problem.
Dan K. Morhaim, MD, Director Department of Emergency Medicine Franklin Square Hospital Baltimore
Author's Reply Yes, we are aware of the use of thrombolytic therapy in the treatment of this disorder. However, in view of the relationship between birth control medication and its effects on antithrombin III levels, we elected to use heparin as the
therapeutic modality.
James R. Sowers, MD VA Medical Center, Sepulveda, California
Oxygen for All Asthmatics on Bronchodilators To the Editor: Martin and coworkers conclude in a recent article ("Use of Peak Expiratory Flow Rates to Eliminate Unnecessary Arterial Blood Gases in Acute Asthma," 11:70-73, February 1982) that PEFR (peak expiratory flow rate) could be used as a tool to decide if ABGs are necessary. Unfortunately they conclude their article with a less-than-vigorous stand by stating that "supplemental oxygen should be considered in all asthmatic patients." The acute asthmatic patient who is in need of bronchodilation has demonstrated an increased pulmonary blood flow out of proportion to the bronchodilation in poorly ventilated areas, thus worsening the already-present ventilation perfusion mismatch (Va/Q) and decreasing PaO2. In those with a low PaO2, a small drop can be dangerous by shifting the oxyhemoglobin dissociation curve toward the steep slope, reducing the amount of oxygen saturation and increasing pulmonary artery pressure with its concomitant
afterload effect on the right ventricle. This decrease in PaO2 can follow a functionally significant improvement in PEFR, so that the patient may obtain relief of his bronchospasm despite a low PaO2.1 Therefore, all asthmatic patients receiving bronchodilators (epinephrine, aminophylline, terbutaline, etc) should receive appropriate amounts of oxygen, whether or not an ABG is necessary.
Donald Forester, MD, Chief Section on Emergency Medicine The Mount Vernon Hospital Mount Vernon, N e w York 1. Flenley DC: Blood gas abnormalities and acute respiratory failure, in Stein M (ed): New Directions in Asthma. American College of Chest Physicians, 1975, pp 495-522.
Author's Reply I call Dr. Forester's attention to the very last sentence in our article: "Because hypoxia is unpredictable both upon presentation and following treatment, supplemental oxygen should be considered in all asthmatic patients." This is the
same point Dr. Forester is making.
Thomas G. Martin, MD Portland, Oregon
Cocaine Intoxication, Delirium, Death In Body Packer To the Editor: The report by Fishbain and Wetli on cocaine intoxication in a body packer (10:531-532, October 1981) is indeed interesting. The clinical presentation of polydipsia, agitation, altered mental status, tachycardia, and increased respiratory rate are not necessarily signs and symptoms of cocaine toxicity. Other disease processes should be considered. The gradual 70/389
deterioration in the patient's mental status indicated at least blood glucose, venous or arterial pH and serum electrolyte determinatiOns. Intravenous administration of naloxone and 50% glucose solution would have been appropriate initial therapy pending laboratory results. An abdominal film did not reveal foreign bodies, but the patient's statement that he swallowed an aluminum foil
Annals of Emergency Medicine
11:7 July 1982
packet of cocaine is accepted. Aluminum is a highly radioopaque metal, and failure to demonstrate this radio-opacity may simply be that the patient is not telling the truth. Another cause for his illness should have been sought, and the patient managed as a potential unknown overdose. It is not uncommon to encounter a violent, unpleasant patient in the emergency department. It is our role as emergency physicians to deal with such patients. The easiest and wrong approach is to label the patient with a diagnosis and transfer him to a remote observation or psychiatric unit without having a clear assessment and some understanding as to the nature of the disease process. It is obvious that the diagnosis of cocaine overdose was never documented by a toxicology screen. A medical diagnosis cannot be based on a police investigation and indirect evidence. Haldol, in our experience, is very effective in managing a violent patient. Sodium amytal may be helpful, provided that the patient is carefully monitored. Respiratory arrest is not usually sudden in onset. Preced-
ing signs and symptoms were probably not monitored and, therefore, other causes of respiratory arrest (eg, cardiac arrhythmia) cannot be excluded. Autopsy findings were pulmonary edema and cerebral edema (probably from long-standing hypoxia). Whether this was a consequence of Cocaine overdose, opiate overdose (in spite of the initial mydriasis), neurogenic pulmonary edema, or something else cannot be ascertained from the work up presented. Given the unreliability of the patient's history, emergency toxicology screens of both urine and blood were clearly indicated in this case.
David Bar-Or, MD Denver General Hospital Emergency Medicine Service Linda Wahby, MD St. Joseph Hospital St. Anthony Hospital Emergency Medicine Service Denver
Author's Reply The patient's change in mental status was not perceived as "deteriorating" because the patientbecame more agitated rather than sedated. The focus of the paper was therefore the recognition of delirium. Steps suggested by Dr. Bar-Or would be appropriate if such recognition could be achieved. Dr. Bar-Or suggests that the patient should have been treated as an "unknown overdose." This decision again depends on the perception by the emergency physician that the change in mental status of the patient is secondary to organic factors. Cause of death was unknown until determined by the medical examiner. This determination was based on the following: 1) ruptured finger cot of cocaine found in the cecum; 2) police investigation labelling the victim as a "body packer"; and 3) blood cocaine levels of .21 mg/LJ (This was not reported in the original paper.) The most widely accepted form of treatment for most drug-induced delirium is haloperidol; 2 however, haloperidol may make an atropine-like delirium worse. It may, therefore, become necessary where the type of delirium is unknown to simply sedate and observe the patient) Sodium amytal and Valium ® could be used for this purpose.
11:7 July 1982
The final cause of death could have been a cardiac arrhythmia. This information is not available, as the final monitoring was done in a psychiatric holding area. This monitoring is usually not very stringent because it is taken for granted that patients referred from medical emergency departments are !'medically clear." "Toxicology screens" are clearly indicated in patients in whom the delirium is of unknown etiology, or when there is an unreliable history.
David A. Fishbain, MD, Director Psychiatric Emergency Services Mental Health Services Division University of Miami School of Medicine Miami 1. Wetli CV, Mettleman RE: The "body packer syndrome": Toxicity following ingestion of illicit drugs packaged for transportation. Forensic Sci 26:492-5000, 1981. 2. Disdafani A, Hall RC, Gardner ERi Drug-induced psychosis: Emergency diagnosis and management. Psychosomatics 22:845855, 1981.
Annals of Emergency Medicine
390/71