- Email: [email protected]
Cocaine intoxication: Massive oral overdose
CASE REPORT
Cocaine Intoxication: Massive Oral Overdose Jeffrey Bettinger, MD Miami, Florida
Massive cocaine intoxication is manifested by central nervous system stimulation (restlessness, tremors, convulsions) and then depression (respiratory and cardiovascular failure). A young man presented with new seizures and eventual development of status epilepticus, respiratory failure, and cardiovascular depression. Investigation revealed ingestion of cocaine-filled condoms which had ruptured in the gastrointestinal tract. Smuggling of illicit drugs via the oral-fecal route may lead to severe physiologic derangements if the container ruptures. Bettinger J: Cocaine intoxication: massive oral overdose. Ann Emerg Med 9:429-430, August 1980.
cocaine intoxication; drug abuse, cocaine; drugs, cocaine, overdose INTRODUCTION The use of cocaine for its central nervous system s t i m u l a n t effects has increased d r a m a t i c a l l y over t h e p a s t few y e a r s in the U n i t e d States. Most cocaine is s m u g g l e d from C e n t r a l or South America, m a k i n g the s o u t h e r n U n i t e d S t a t e s cities i m p o r t a n t p o i n t s of entry. Recreational use of cocaine is u s u a l l y via int r a v e n o u s (IV) or n a s a l routes. The following case report describes the physiologic effects of m a s s i v e oral intoxication of cocaine.
CASE REPORT A 22-year-old white m a n from A u s t r a l i a was a d m i t t e d to Cedars of Lebanon H e a l t h C a r e C e n t e r following his first convulsion. S h o r t l y a f t e r a r r i v a l in M i a m i , t h e p a t i e n t developed dizziness while walking, t h e n proceeded to have a g r a n d m a l seizure. He was t r a n s p o r t e d to the hospital by M i a m i City F i r e Rescue. I n the emergency d e p a r t m e n t , t h e p a t i e n t h a d a n o t h e r g r a n d m a l seizure a n d was t r e a t e d with 400 m g IV phenytoin, 10 m g IV diazepam, and 200 mg IV p h e n o b a r b i t a l . The p a t i e n t was t r a n s i e n t l y confused postictal, b u t then r e g a i n e d full orientation. He denied prior t r a u m a , seizures, neurologic or cardiac disease, fever, or o t h e r significant medical history. He a d m i t t e d to the occasional use of e t h a n o l and m a r i j u a n a . Recent t r a v e l history included E a s t e r Island, Peru, and Chile. E x a m i n a t i o n r e v e a l e d a m u s c u l a r , m i l d l y confused m a n in a postictal state. H i s pulse was 100 beats/min; blood pressure, 160/110 m m Hg; t e m p e r a t u r e , 37.22 C (R); r e s p i r a t o r y r a t e , 14 breaths/min. His s k i n was w a r m and flushed. F u n d i were n o r m a l with flat discs and venous pulsations. Neck was supple with no j u g u l a r venous distention. Tongue and scalp h a d t i n y lacerations. Exami n a t i o n s of the heart, lungs, abdomen, and e x t r e m i t i e s were all normal. There were no needle tracks. Neurologic e x a m i n a t i o n showed an alert, slightly confused man. Pupils were 8 m m and b r i s k l y reactive. E x a m i n a t i o n s of the c r a n i a l nerves, reflexes, a n d m o t o r a n d sensory m o d a l i t i e s were a l l w i t h i n n o r m a l limits. From the Department of Medicine, Cedars of Lebanon Health Care Center, Miami, Florida. Address for reprints: Jeffrey Bettinger, MD, Emergency Medical Group of Miami, PA, Box 637, Quail Heights Branch, Miami, Florida 33197.
9:8 (August) 1980
Ann Emerg Med
429/57
I n i t i a l l a b o r a t o r y r e s u l t s revealed the following: the white blood cell c o u n t was 12,700/cu mm. The a n i o n gap was 21, with a serum bic a r b o n a t e of 23 m E q / l i t e r . S k u l l r a d i o g r a p h s were normal. Cerebral spinal fluid had one white blood cell. T h e o p e n i n g p r e s s u r e of l u m b a r p u n c t u r e was 11.5 cm I-hO.
HOSPITAL COURSE The patient was placed in the int e n s i v e care u n i t for o b s e r v a t i o n . P h e n y t o i n 100 mg and p h e n o b a r b i t a l 30 mg were given three times daily. No further seizures occurred and the p a t i e n t was transferred to a r e g u l a r hospital room 24 h r later, at which t i m e the neurologic e x a m i n a t i o n was n o r m a l . Two days after admission, t h e p a t i e n t was found cyanotic and h a v i n g seizures. He was i n t u b a t e d , b u t c o n t i n u e d to h a v e seizures for the next 4 h r despite receiving adeq u a t e v e n t i l a t i o n a n d a total of 400 m g IV p h e n o b a r b i t a l , 1.5 g m IV a m o b a r b i t a l , 400 mg IV phenytoin, a n d 10 mg IV diazepam. When the seizures were finally controlled, the p a t i e n t was v e n t i l a t o r dependent and receiving low-dose dopamine for support of blood pressure. Postictal temp e r a t u r e was 42.05 C (R). A cerebral a n g i o g r a p h i c study of both carotid arteries and the right vertebral artery was normal. Over the next 24 hr, the p a t i e n t ' s condition improved to the point at which he no longer r e q u i r e d d o p a m i n e or v e n t i l a t o r y support. His m e n t a l status, however, varied between extreme agitation a n d nomresponsiveness. There were no localizing neurologic signs. A p p r o x i m a t e l y 72 h r after admission, it was decided to search the p a t i e n t ' s b e l o n g i n g s for a possible causative a g e n t (ie, drugs) of his seiz u r e s . I n s i d e his k n a p s a c k t h e r e were three fecal-stained, thumb-sized plastic bags c o n t a i n i n g a white powder. Rectal e x a m i n a t i o n revealed a piece of a broken plastic bag in the rectal vault. E x a m i n a t i o n of the contents of the plaStic bags by the Dade County Medical E x a m i n e r ' s Office revealed cocaine. The patient's s e r u m cocaine
58/430
level at 72 hr post-admission was 200 p gm%. For the r e m a i n d e r of the hospital course the p a t i e n t g r a d u a l l y imp r o v e d . T h e p a t i e n t a d m i t t e d to s w a l l o w i n g the c o c a i n e - f i l l e d condoms w h i l e i n P e r u , p r i o r to h i s flight to Miami. There was no evidence of n e u r o l o g i c r e s i d u e , other t h a n a m n e s i a , for the few days following the seizures.
DISCUSSION Cocaine s t i m u l a t e s the c e n t r a l n e r v o u s system from ~abc~:e downward. ''1 Initially effects are seen on the c e r e b r a l cortex, a n d are m a n ifested as excitement or restlessness. As the dose is increased, lower motor centers are stimulated: causing tremors and convulsive movements. Cord r e f l e x e s a r e i n c r e a s e d a n d t o n i c - c l o n i c s e i z u r e s m a y occur. B r a i n s t e m effects may lead to tachyp n e a a n d t a c h y c a r d i a a n d emesis. With higher doses, central nervous system depression ensues in a downward fashion. R e s p i r a t o r y a n d card i o v a s c u l a r depression m a y occur. Other effects of cocaine include hyperthermia, increased sympathetic tone, local blockage of nerve conduction, and mydriasis. 1 Mebane and DeVito 2 described a case of massive cocaine intoxication i n a 19-year-old woman secondary to r u p t u r e of two cocaine-filled ~fingercot balloons." Symptoms manifested were g r a n d m a l s e i z u r e s a n d respiratory arrest. S u a r e z et a l 3 r e p o r t e d t h r e e cases of massive cocaine overdosage secondary to r u p t u r e of cocaine-cont a i n i n g condoms ingested in smugg l i n g attempts. Diagnosis was made by post-mortem e x a m i n a t i o n in two of the p a t i e n t s and by history, endoscopy, and laparotomy in the third. F a i n s i n g e r 4 d e s c r i b e d the app e a r a n c e of multiple, oval, soft tissue densities seen w i t h i n the bowel on a flat plate of the abdomen. Each density was l~/ighlighted by a gas halo. The p a t i e n t had ingested 180 latex bags c o n t a i n i n g cocaine. The abdominal film in this case did not reveal a n y foreign bodies.
Ann
Emerg Med
Our case is the first reported in. cidence of cocaine-filled condom rup. ture in Miami, after a two-year hiatus from a rash of deaths which occurred from this complication (per. s o n a l c o m m u n i c a t i o n , Dr. Ronald Wright, Deputy Chief Medical Exam. iner, Dade County, Florida). At that t i m e , w a r n i n g s were distributed t h r o u g h a variety of youth-oriented " u n d e r g r o u n d " n e w s p a p e r s , outlin. i n g the potential toxicity of ingestion of cocaine-filled condoms. Apparently t h e p u b l i c i t y was effective i n de. c r e a s i n g the problem of accidental oral cocaine overdose. A repeat warning to the same audience appears t0 be i n order. Emergency departments, especially in Cities serving as entry points from L a t i n America, should be a l e r t to this form of drug overdosage.
CONCLUSION Our case accentuates the importance of suspecting central nervous system s t i m u l a n t s in all cases of new seizures, even with a negative history. A qualitative toxicology screen was not performed. Performance of such a test m a y not have led to a d i a g n o s i s of i n g e s t i o n of cocainefilled condoms, but would have established the p a t i e n t as a n unreliable h i s t o r i a n and led to f u r t h e r quantitative screening. The use of massive a m o u n t s of a n t i - c o n v u l s a n t s for control of seizures, as occurred i n this patient, is n o t g e n e r a l l y r e q u i r e d for seizures secondary to epilepsy. Thus in cases i n which large doses of anti-convuls a n t s are required, the emergency p h y s i c i a n s h o u l d s t r o n g l y suspect a n d search for drug-induced seizures.
REFERENCES 1. Ritchie JM, Cohen PJ: Cocaine: procaine and other synthetic local anesthetics, in Goodman LS, Gilman A (eds): Pharmacologic Basis of Therapeutics, ed 5. New York, MacMillan Co, 1975. 2. Mebane C, DeVito J: Cocaine intoxication. J Fla Med Assoc 62:19, 1975. 3. Suarez C, Arango A, Lester L: Cocaine-condom ingestion. JAMA 238:13911392, 1977. 4. Fainsinger M: Unusual foreign bodies in bowel. JAMA 237:2225-2226, 1977.
9:8 (August) 1980
Cocaine Intoxication: Massive Oral Overdose Jeffrey Bettinger, MD Miami, Florida
Massive cocaine intoxication is manifested by central nervous system stimulation (restlessness, tremors, convulsions) and then depression (respiratory and cardiovascular failure). A young man presented with new seizures and eventual development of status epilepticus, respiratory failure, and cardiovascular depression. Investigation revealed ingestion of cocaine-filled condoms which had ruptured in the gastrointestinal tract. Smuggling of illicit drugs via the oral-fecal route may lead to severe physiologic derangements if the container ruptures. Bettinger J: Cocaine intoxication: massive oral overdose. Ann Emerg Med 9:429-430, August 1980.
cocaine intoxication; drug abuse, cocaine; drugs, cocaine, overdose INTRODUCTION The use of cocaine for its central nervous system s t i m u l a n t effects has increased d r a m a t i c a l l y over t h e p a s t few y e a r s in the U n i t e d States. Most cocaine is s m u g g l e d from C e n t r a l or South America, m a k i n g the s o u t h e r n U n i t e d S t a t e s cities i m p o r t a n t p o i n t s of entry. Recreational use of cocaine is u s u a l l y via int r a v e n o u s (IV) or n a s a l routes. The following case report describes the physiologic effects of m a s s i v e oral intoxication of cocaine.
CASE REPORT A 22-year-old white m a n from A u s t r a l i a was a d m i t t e d to Cedars of Lebanon H e a l t h C a r e C e n t e r following his first convulsion. S h o r t l y a f t e r a r r i v a l in M i a m i , t h e p a t i e n t developed dizziness while walking, t h e n proceeded to have a g r a n d m a l seizure. He was t r a n s p o r t e d to the hospital by M i a m i City F i r e Rescue. I n the emergency d e p a r t m e n t , t h e p a t i e n t h a d a n o t h e r g r a n d m a l seizure a n d was t r e a t e d with 400 m g IV phenytoin, 10 m g IV diazepam, and 200 mg IV p h e n o b a r b i t a l . The p a t i e n t was t r a n s i e n t l y confused postictal, b u t then r e g a i n e d full orientation. He denied prior t r a u m a , seizures, neurologic or cardiac disease, fever, or o t h e r significant medical history. He a d m i t t e d to the occasional use of e t h a n o l and m a r i j u a n a . Recent t r a v e l history included E a s t e r Island, Peru, and Chile. E x a m i n a t i o n r e v e a l e d a m u s c u l a r , m i l d l y confused m a n in a postictal state. H i s pulse was 100 beats/min; blood pressure, 160/110 m m Hg; t e m p e r a t u r e , 37.22 C (R); r e s p i r a t o r y r a t e , 14 breaths/min. His s k i n was w a r m and flushed. F u n d i were n o r m a l with flat discs and venous pulsations. Neck was supple with no j u g u l a r venous distention. Tongue and scalp h a d t i n y lacerations. Exami n a t i o n s of the heart, lungs, abdomen, and e x t r e m i t i e s were all normal. There were no needle tracks. Neurologic e x a m i n a t i o n showed an alert, slightly confused man. Pupils were 8 m m and b r i s k l y reactive. E x a m i n a t i o n s of the c r a n i a l nerves, reflexes, a n d m o t o r a n d sensory m o d a l i t i e s were a l l w i t h i n n o r m a l limits. From the Department of Medicine, Cedars of Lebanon Health Care Center, Miami, Florida. Address for reprints: Jeffrey Bettinger, MD, Emergency Medical Group of Miami, PA, Box 637, Quail Heights Branch, Miami, Florida 33197.
9:8 (August) 1980
Ann Emerg Med
429/57
I n i t i a l l a b o r a t o r y r e s u l t s revealed the following: the white blood cell c o u n t was 12,700/cu mm. The a n i o n gap was 21, with a serum bic a r b o n a t e of 23 m E q / l i t e r . S k u l l r a d i o g r a p h s were normal. Cerebral spinal fluid had one white blood cell. T h e o p e n i n g p r e s s u r e of l u m b a r p u n c t u r e was 11.5 cm I-hO.
HOSPITAL COURSE The patient was placed in the int e n s i v e care u n i t for o b s e r v a t i o n . P h e n y t o i n 100 mg and p h e n o b a r b i t a l 30 mg were given three times daily. No further seizures occurred and the p a t i e n t was transferred to a r e g u l a r hospital room 24 h r later, at which t i m e the neurologic e x a m i n a t i o n was n o r m a l . Two days after admission, t h e p a t i e n t was found cyanotic and h a v i n g seizures. He was i n t u b a t e d , b u t c o n t i n u e d to h a v e seizures for the next 4 h r despite receiving adeq u a t e v e n t i l a t i o n a n d a total of 400 m g IV p h e n o b a r b i t a l , 1.5 g m IV a m o b a r b i t a l , 400 mg IV phenytoin, a n d 10 mg IV diazepam. When the seizures were finally controlled, the p a t i e n t was v e n t i l a t o r dependent and receiving low-dose dopamine for support of blood pressure. Postictal temp e r a t u r e was 42.05 C (R). A cerebral a n g i o g r a p h i c study of both carotid arteries and the right vertebral artery was normal. Over the next 24 hr, the p a t i e n t ' s condition improved to the point at which he no longer r e q u i r e d d o p a m i n e or v e n t i l a t o r y support. His m e n t a l status, however, varied between extreme agitation a n d nomresponsiveness. There were no localizing neurologic signs. A p p r o x i m a t e l y 72 h r after admission, it was decided to search the p a t i e n t ' s b e l o n g i n g s for a possible causative a g e n t (ie, drugs) of his seiz u r e s . I n s i d e his k n a p s a c k t h e r e were three fecal-stained, thumb-sized plastic bags c o n t a i n i n g a white powder. Rectal e x a m i n a t i o n revealed a piece of a broken plastic bag in the rectal vault. E x a m i n a t i o n of the contents of the plaStic bags by the Dade County Medical E x a m i n e r ' s Office revealed cocaine. The patient's s e r u m cocaine
58/430
level at 72 hr post-admission was 200 p gm%. For the r e m a i n d e r of the hospital course the p a t i e n t g r a d u a l l y imp r o v e d . T h e p a t i e n t a d m i t t e d to s w a l l o w i n g the c o c a i n e - f i l l e d condoms w h i l e i n P e r u , p r i o r to h i s flight to Miami. There was no evidence of n e u r o l o g i c r e s i d u e , other t h a n a m n e s i a , for the few days following the seizures.
DISCUSSION Cocaine s t i m u l a t e s the c e n t r a l n e r v o u s system from ~abc~:e downward. ''1 Initially effects are seen on the c e r e b r a l cortex, a n d are m a n ifested as excitement or restlessness. As the dose is increased, lower motor centers are stimulated: causing tremors and convulsive movements. Cord r e f l e x e s a r e i n c r e a s e d a n d t o n i c - c l o n i c s e i z u r e s m a y occur. B r a i n s t e m effects may lead to tachyp n e a a n d t a c h y c a r d i a a n d emesis. With higher doses, central nervous system depression ensues in a downward fashion. R e s p i r a t o r y a n d card i o v a s c u l a r depression m a y occur. Other effects of cocaine include hyperthermia, increased sympathetic tone, local blockage of nerve conduction, and mydriasis. 1 Mebane and DeVito 2 described a case of massive cocaine intoxication i n a 19-year-old woman secondary to r u p t u r e of two cocaine-filled ~fingercot balloons." Symptoms manifested were g r a n d m a l s e i z u r e s a n d respiratory arrest. S u a r e z et a l 3 r e p o r t e d t h r e e cases of massive cocaine overdosage secondary to r u p t u r e of cocaine-cont a i n i n g condoms ingested in smugg l i n g attempts. Diagnosis was made by post-mortem e x a m i n a t i o n in two of the p a t i e n t s and by history, endoscopy, and laparotomy in the third. F a i n s i n g e r 4 d e s c r i b e d the app e a r a n c e of multiple, oval, soft tissue densities seen w i t h i n the bowel on a flat plate of the abdomen. Each density was l~/ighlighted by a gas halo. The p a t i e n t had ingested 180 latex bags c o n t a i n i n g cocaine. The abdominal film in this case did not reveal a n y foreign bodies.
Ann
Emerg Med
Our case is the first reported in. cidence of cocaine-filled condom rup. ture in Miami, after a two-year hiatus from a rash of deaths which occurred from this complication (per. s o n a l c o m m u n i c a t i o n , Dr. Ronald Wright, Deputy Chief Medical Exam. iner, Dade County, Florida). At that t i m e , w a r n i n g s were distributed t h r o u g h a variety of youth-oriented " u n d e r g r o u n d " n e w s p a p e r s , outlin. i n g the potential toxicity of ingestion of cocaine-filled condoms. Apparently t h e p u b l i c i t y was effective i n de. c r e a s i n g the problem of accidental oral cocaine overdose. A repeat warning to the same audience appears t0 be i n order. Emergency departments, especially in Cities serving as entry points from L a t i n America, should be a l e r t to this form of drug overdosage.
CONCLUSION Our case accentuates the importance of suspecting central nervous system s t i m u l a n t s in all cases of new seizures, even with a negative history. A qualitative toxicology screen was not performed. Performance of such a test m a y not have led to a d i a g n o s i s of i n g e s t i o n of cocainefilled condoms, but would have established the p a t i e n t as a n unreliable h i s t o r i a n and led to f u r t h e r quantitative screening. The use of massive a m o u n t s of a n t i - c o n v u l s a n t s for control of seizures, as occurred i n this patient, is n o t g e n e r a l l y r e q u i r e d for seizures secondary to epilepsy. Thus in cases i n which large doses of anti-convuls a n t s are required, the emergency p h y s i c i a n s h o u l d s t r o n g l y suspect a n d search for drug-induced seizures.
REFERENCES 1. Ritchie JM, Cohen PJ: Cocaine: procaine and other synthetic local anesthetics, in Goodman LS, Gilman A (eds): Pharmacologic Basis of Therapeutics, ed 5. New York, MacMillan Co, 1975. 2. Mebane C, DeVito J: Cocaine intoxication. J Fla Med Assoc 62:19, 1975. 3. Suarez C, Arango A, Lester L: Cocaine-condom ingestion. JAMA 238:13911392, 1977. 4. Fainsinger M: Unusual foreign bodies in bowel. JAMA 237:2225-2226, 1977.
9:8 (August) 1980