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Post-hypoxic ascites or hepatic vein thrombosis
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Correspondence F~ropranolol Combats Cocaine Effects ro the Editor: After experience with over 50 cases of cocaine "overi0se" my colleagues, Drs. Rappolt and Inaba, and I have f0und that propranolol (Inderal) has strikingly specific antagonistic effects on the manifestations of central cardiovascular hypermetabolism. After two years of using the drug, often when providing medical services to outdoor rock concerts, we are especially impressed with the ~pecificity of propranolol's action in blocking the cardiovascular pressor effects of cocaine. Our experience ihows t h a t a dosage of 1 mg per m i n u t e , up to a maximum dose of 6 mg to 8 mg, will specifically and with ~bsolute safety reverse the hypertension, tachycardia and tachypnea that places the patient in danger of cerebrovascular accident or acute congestive heart failure (or imminent death from cardiac arrhythmias).
CASE REPORT During a rock music concert, medical help was sought f0r a performer who had a history of use of a ~'large" ~mount of cocaine, the last dose just a few minutes prior to examination, and having been up all night. He exhibited the symptoms of chronic adrenergic overtstimulation. He spoke in rapid staccato bursts and was initially quite suspicious and difficult to examine. He Was pale, nervous and his extremities were visibly shaking. His pupils were dilated (5 to 6 ml) but light reactive. His mucous membranes were pale and dry. He was intermittently retching and had evidently previously vomIted some bile-stained mucoid material. His apical pulse ~was140, his peripheral pulse was also 140 but thready, Fweak and difficult to palpate. No rhythm irregularities were noted. His hands were pale, cold and dry. His blood pressure, also hard to determine, was 220/160 bilaterally by auscultation. Respirations were 40/minute and somewhat shallow. He was observed for 15 minutes while at rest during which t i m e his vital signs remained essentially unchanged. At this time propranolol hydrochloride (Inderal) was administered 1 mg intravenously. Within 60 seconds his pulse rate was 120, blood pressure was 200/120 bilatierally and respirations were 32/minute. Over the ensuing five minutes he was given 1 mg of propranolol at one ~inute intervals. At ten minutes following the initial dose, his pulse rate was 88, blood pressure was 140/86 and respirations were,18/minute. The peripheral tremors had abated and his central color was better although his e~tremities remained somewhat cold and dry. His pupils reraained dilated (4 mm). His mucous membranes re• ained dry. His sens0rium revealed much less anxiety aad he was given prochlorperazine (Compazine), 10 mg iatravenously, whereupon immediate relief of retching ~as noted. 1976 •PJuly
At this point, some 30 minutes after first being seen, he was remarkably free of his initial symptoms and physical signs. His pulse rate was 78, blood pressure was 120/70 b i l a t e r a l l y , r e s p i r a t i o n s were 14/minute. Peripheral and central color were good. He was free of tremor and retching. After an additional 15 minutes of rest (during which all signs remained normal), he was slowly assisted to the sitting position. Blood pressure remained 120/70, pulse was 74, respirations were 12/minute. He spoke rationally and at a normal rate; he said that he felt he could "go on now." Within another 15 minutes he was onstage and playing with his group. He was given a prescription for flurazepam (Dalmane), 60 mg hs, and for diazepam (Vatium), 10 mg tid, to be taken over the ensuing week. The protocol used in the above case may be an exciting new therapeutic modality for the emergency physician who encounters patients with signs and symptoms of cocaine overuse in this, the "snorting seventies."
George R. Gay, MD, FAAFP Mendocino, California
Post-Hypoxic Ascites or
Hepatic Vein Thrombosis To the Editor: In regard to the case report, '~Post-Hypoxic Ascites: A Cause of Post-traumatic Abdominal Distention," by Drs. Urlaub and Moylan in the March JACEP, one wonders whether the new entity described is not in fact the old entity of hepatic vein thrombosis (Budd-Chiari syndrome) with partial obstruction and recanalization.
T. A. Moore, III, MD Charity Hospital of Louisiana New Orleans, Louisiana
Author's Reply To the Editor: In response to Dr. Moore, we considered the diagnosis of hepatic vein thrombosis at that time. However, the clinical course with rapid resolution of the hepatic enlargement ascites and liver function did not seem consistent with hepatic vein thrombosis. In our experience, recanalization of thrombosed veins takes a number of weeks until flow returns. In addition, the patient had no trauma to the abdomen or other reason for hepatic vein thrombosis.
Joseph A. Moylan, MD Associate Professor of Surgery Duke University Medical Center Volume 5 Number 7 Page 549
Correspondence F~ropranolol Combats Cocaine Effects ro the Editor: After experience with over 50 cases of cocaine "overi0se" my colleagues, Drs. Rappolt and Inaba, and I have f0und that propranolol (Inderal) has strikingly specific antagonistic effects on the manifestations of central cardiovascular hypermetabolism. After two years of using the drug, often when providing medical services to outdoor rock concerts, we are especially impressed with the ~pecificity of propranolol's action in blocking the cardiovascular pressor effects of cocaine. Our experience ihows t h a t a dosage of 1 mg per m i n u t e , up to a maximum dose of 6 mg to 8 mg, will specifically and with ~bsolute safety reverse the hypertension, tachycardia and tachypnea that places the patient in danger of cerebrovascular accident or acute congestive heart failure (or imminent death from cardiac arrhythmias).
CASE REPORT During a rock music concert, medical help was sought f0r a performer who had a history of use of a ~'large" ~mount of cocaine, the last dose just a few minutes prior to examination, and having been up all night. He exhibited the symptoms of chronic adrenergic overtstimulation. He spoke in rapid staccato bursts and was initially quite suspicious and difficult to examine. He Was pale, nervous and his extremities were visibly shaking. His pupils were dilated (5 to 6 ml) but light reactive. His mucous membranes were pale and dry. He was intermittently retching and had evidently previously vomIted some bile-stained mucoid material. His apical pulse ~was140, his peripheral pulse was also 140 but thready, Fweak and difficult to palpate. No rhythm irregularities were noted. His hands were pale, cold and dry. His blood pressure, also hard to determine, was 220/160 bilaterally by auscultation. Respirations were 40/minute and somewhat shallow. He was observed for 15 minutes while at rest during which t i m e his vital signs remained essentially unchanged. At this time propranolol hydrochloride (Inderal) was administered 1 mg intravenously. Within 60 seconds his pulse rate was 120, blood pressure was 200/120 bilatierally and respirations were 32/minute. Over the ensuing five minutes he was given 1 mg of propranolol at one ~inute intervals. At ten minutes following the initial dose, his pulse rate was 88, blood pressure was 140/86 and respirations were,18/minute. The peripheral tremors had abated and his central color was better although his e~tremities remained somewhat cold and dry. His pupils reraained dilated (4 mm). His mucous membranes re• ained dry. His sens0rium revealed much less anxiety aad he was given prochlorperazine (Compazine), 10 mg iatravenously, whereupon immediate relief of retching ~as noted. 1976 •PJuly
At this point, some 30 minutes after first being seen, he was remarkably free of his initial symptoms and physical signs. His pulse rate was 78, blood pressure was 120/70 b i l a t e r a l l y , r e s p i r a t i o n s were 14/minute. Peripheral and central color were good. He was free of tremor and retching. After an additional 15 minutes of rest (during which all signs remained normal), he was slowly assisted to the sitting position. Blood pressure remained 120/70, pulse was 74, respirations were 12/minute. He spoke rationally and at a normal rate; he said that he felt he could "go on now." Within another 15 minutes he was onstage and playing with his group. He was given a prescription for flurazepam (Dalmane), 60 mg hs, and for diazepam (Vatium), 10 mg tid, to be taken over the ensuing week. The protocol used in the above case may be an exciting new therapeutic modality for the emergency physician who encounters patients with signs and symptoms of cocaine overuse in this, the "snorting seventies."
George R. Gay, MD, FAAFP Mendocino, California
Post-Hypoxic Ascites or
Hepatic Vein Thrombosis To the Editor: In regard to the case report, '~Post-Hypoxic Ascites: A Cause of Post-traumatic Abdominal Distention," by Drs. Urlaub and Moylan in the March JACEP, one wonders whether the new entity described is not in fact the old entity of hepatic vein thrombosis (Budd-Chiari syndrome) with partial obstruction and recanalization.
T. A. Moore, III, MD Charity Hospital of Louisiana New Orleans, Louisiana
Author's Reply To the Editor: In response to Dr. Moore, we considered the diagnosis of hepatic vein thrombosis at that time. However, the clinical course with rapid resolution of the hepatic enlargement ascites and liver function did not seem consistent with hepatic vein thrombosis. In our experience, recanalization of thrombosed veins takes a number of weeks until flow returns. In addition, the patient had no trauma to the abdomen or other reason for hepatic vein thrombosis.
Joseph A. Moylan, MD Associate Professor of Surgery Duke University Medical Center Volume 5 Number 7 Page 549