- Email: [email protected]
Treatment of cocaine toxicity
CORRESPONDENCE
TABLE. Fluid and electrolyte replacement
Hours After Injury 0-6
H20 (mL)
Actual Na + (mEq) K ÷ (mEq) CI- (mEq)
Calculated H20 (mL) Na+ (mEq) K+ (mEq)
CI- (mEq)
0
0
0
0
363
23
3.0
23
6-12
600
21
6
27
325
18
2.8
19
12-18
600
23
6.6
30
306
16
2.7
17
Totals
1,260
44
12.6
57
994
57
8.5
59
w i t h a d m i n i s t r a t i o n of h y p o t o n i c IV solution, has b e e n w e l l recognized in the burn and trauma literature since M c M a n u s , H u n t , and Pruitt's original report in 1974. 8 We t h a n k the editor for the o p p o r t u n i t y to try and correct this c o m m o n m i s p e r c e p t i o n and again stress that this case does n o t represent SIADH, but an iatrogenic c o m p l i c a t i o n f r o m a d m i n i s t r a t i o n of h y p o t o n i c fluids to treat a p a t i e n t w i t h a physiologically appropriate increased A D H secretion.
Gregory A Timberlake, M D Norman E McSwain, Jr, M D Department of Surgery Tulane University School of Medicine N e w Orleans, Louisiana
of Cocaine
4. Davis JO, Hartroft PM, Titus EO, et ah The role of the renin-angiotensin system in the control of aldosterone secretion. J Clin Invest 1962; 41:378-389.
6. Braen GR, Jelenko C III: Thermal injuries, in Rosen P (ed): Emergency Medicine. St Louis, CV Mosby Co, 1983, p 433-443. 7. Committee on Trauma of the American College of Surgeons: Burns, in Advanced Trauma Life Support Course of Physicians. 1984, Chicago, ACS, p i55-163. 8. McManus WF, Hunt JL, Pruit BA Jr: Postburn convulsive disorders in children. J Trauma 1974;376-401.
Toxicity
To the Editor: Dusenberry, Hicks, and M a r i a n i reported the successful t r e a t m e n t of a c o c a i n e - i n t o x i c a t e d p a t i e n t w i t h l a b e t a l o l and suggested t h e use of this agent in t h e m a n a g e m e n t of s u c h h y p e r a d r e n e r g i c s t a t e s as p h e o c h r o m o c y t o m a a n d s t i m u l a n t drug t o x i c i t y (cocaine, a m p h e t a m i n e s , and overt h e - c o u n t e r s t i m u l a n t s ) [ F e b r u a r y 1987;16:235]. L a b e t a l o l has b o t h alpha and b e t a a d r e n e r g i c b l o c k i n g p r o p e r t i e s ; thus, its use in h y p e r c a t e c h o l a m i n e states is logical. However, labetalol s h o u l d be u s e d w i t h c a u t i o n in patients with adrenergic hyperactivity. The beta blocking properties of labetalol are m u c h m o r e p o t e n t t h a n its alpha b l o c k i n g properties.i, 2 Like propranolol, l a b e t a l o l has t h e potential to cause a state of relatively u n o p p o s e d alpha effect, thereby raising the blood pressure. T h i s is m o r e t h a n a t h e o r e t i c a l c o n s i d e r a t i o n ; p a r a d o x i c a l i n c r e a s e s in b l o o d pressure have occurred in h y p e r t e n s i v e patients w i t h pheoc h r o m o c y t o m a s w h o were given labetalol.3, 4 We have used labetalol successfully in patients w i t h hypertension due to a m p h e t a m i n e toxicity, and h a v e n o t observed any adverse effects. However, one m u s t be aware t h a t like propranolol, labetalol m a y w o r s e n h y p e r t e n s i o n in pa-
140/922
3. Dudley HI:, Boiing EA, LeQuesne LP, et al: Studies on antidiuresis in surgery: Effects of anesthesia, surgery, and posterior pituitary anti-diuretic hormones on water metabolism in man. Ann Surg 1954;140:354-367.
5. McManus WF: Immediate emergency department care, in Artz CP, Moncrief JA, Pruitt BA Jr (eds): Burns: A Team Approach. Philadelphia, WB Saunders Co, 1979, p 159-I64.
REFERENCES 1. Gann DS, Amaral Jl:: Pathophysiology of trauma and shock, in Zuidema GD, Rutherford RB, Ballinger WR (eds): The Management of Trauma, ed 4. Philadelphia, WB Saunders Co, 1985, p 37-103.
Treatment
2. Mirsky IA, Stein M, Paulisch G: The secretion of an antidiuretic substance into the circulation of adrenalectomized and hypophysectomized rats exposed to noxious stimuli. Endocrinology 1954;55:28-39.
t i e n t s w i t h h y p e r a d r e n e r g i c states. If t h e s e p a t i e n t s are g i v e n l a b e t a l o l t h e y s h o u l d be o b s e r v e d c a r e f u l l y for increases in b l o o d pressure. If s u c h a c o m p l i c a t i o n ensues, t r e a t m e n t w i t h a pure alpha blocker such as p h e n t o l a m i n e , or a vasodilator such as nitroprusside, diazoxide, or possibly nifedipine, is indicated.
Howard A Bessen, MD, FACEP Department of Emergency Medicine Harbor- UCLA Medical Center Torrance, California 1. Wallin JD, O'Neill WM: Labetaloh Current research and therapeutic status. Arch Intern Med 1983;143:485-490. 2. Wilson DJ, Wallin JD, Vlachakis ND, et ah Intravenous labetalol in the treatment of severe hypertension and hypertensive emergencies. Am JMed 1983;75:95-i02. 3. Briggs RSJ, BirtwelI AJ, PohI JEF: Hypertension response to iabetalol in phaeochromocytoma. Lancet I978;h1045-1046. 4. Feek CM, Earnshaw PM: Hypertensive response to labetaloi in phaeochromocyt0ma. Br Med J 1980;281:387.
Annals of Emergency Medicine
16:8 August 1987
TABLE. Fluid and electrolyte replacement
Hours After Injury 0-6
H20 (mL)
Actual Na + (mEq) K ÷ (mEq) CI- (mEq)
Calculated H20 (mL) Na+ (mEq) K+ (mEq)
CI- (mEq)
0
0
0
0
363
23
3.0
23
6-12
600
21
6
27
325
18
2.8
19
12-18
600
23
6.6
30
306
16
2.7
17
Totals
1,260
44
12.6
57
994
57
8.5
59
w i t h a d m i n i s t r a t i o n of h y p o t o n i c IV solution, has b e e n w e l l recognized in the burn and trauma literature since M c M a n u s , H u n t , and Pruitt's original report in 1974. 8 We t h a n k the editor for the o p p o r t u n i t y to try and correct this c o m m o n m i s p e r c e p t i o n and again stress that this case does n o t represent SIADH, but an iatrogenic c o m p l i c a t i o n f r o m a d m i n i s t r a t i o n of h y p o t o n i c fluids to treat a p a t i e n t w i t h a physiologically appropriate increased A D H secretion.
Gregory A Timberlake, M D Norman E McSwain, Jr, M D Department of Surgery Tulane University School of Medicine N e w Orleans, Louisiana
of Cocaine
4. Davis JO, Hartroft PM, Titus EO, et ah The role of the renin-angiotensin system in the control of aldosterone secretion. J Clin Invest 1962; 41:378-389.
6. Braen GR, Jelenko C III: Thermal injuries, in Rosen P (ed): Emergency Medicine. St Louis, CV Mosby Co, 1983, p 433-443. 7. Committee on Trauma of the American College of Surgeons: Burns, in Advanced Trauma Life Support Course of Physicians. 1984, Chicago, ACS, p i55-163. 8. McManus WF, Hunt JL, Pruit BA Jr: Postburn convulsive disorders in children. J Trauma 1974;376-401.
Toxicity
To the Editor: Dusenberry, Hicks, and M a r i a n i reported the successful t r e a t m e n t of a c o c a i n e - i n t o x i c a t e d p a t i e n t w i t h l a b e t a l o l and suggested t h e use of this agent in t h e m a n a g e m e n t of s u c h h y p e r a d r e n e r g i c s t a t e s as p h e o c h r o m o c y t o m a a n d s t i m u l a n t drug t o x i c i t y (cocaine, a m p h e t a m i n e s , and overt h e - c o u n t e r s t i m u l a n t s ) [ F e b r u a r y 1987;16:235]. L a b e t a l o l has b o t h alpha and b e t a a d r e n e r g i c b l o c k i n g p r o p e r t i e s ; thus, its use in h y p e r c a t e c h o l a m i n e states is logical. However, labetalol s h o u l d be u s e d w i t h c a u t i o n in patients with adrenergic hyperactivity. The beta blocking properties of labetalol are m u c h m o r e p o t e n t t h a n its alpha b l o c k i n g properties.i, 2 Like propranolol, l a b e t a l o l has t h e potential to cause a state of relatively u n o p p o s e d alpha effect, thereby raising the blood pressure. T h i s is m o r e t h a n a t h e o r e t i c a l c o n s i d e r a t i o n ; p a r a d o x i c a l i n c r e a s e s in b l o o d pressure have occurred in h y p e r t e n s i v e patients w i t h pheoc h r o m o c y t o m a s w h o were given labetalol.3, 4 We have used labetalol successfully in patients w i t h hypertension due to a m p h e t a m i n e toxicity, and h a v e n o t observed any adverse effects. However, one m u s t be aware t h a t like propranolol, labetalol m a y w o r s e n h y p e r t e n s i o n in pa-
140/922
3. Dudley HI:, Boiing EA, LeQuesne LP, et al: Studies on antidiuresis in surgery: Effects of anesthesia, surgery, and posterior pituitary anti-diuretic hormones on water metabolism in man. Ann Surg 1954;140:354-367.
5. McManus WF: Immediate emergency department care, in Artz CP, Moncrief JA, Pruitt BA Jr (eds): Burns: A Team Approach. Philadelphia, WB Saunders Co, 1979, p 159-I64.
REFERENCES 1. Gann DS, Amaral Jl:: Pathophysiology of trauma and shock, in Zuidema GD, Rutherford RB, Ballinger WR (eds): The Management of Trauma, ed 4. Philadelphia, WB Saunders Co, 1985, p 37-103.
Treatment
2. Mirsky IA, Stein M, Paulisch G: The secretion of an antidiuretic substance into the circulation of adrenalectomized and hypophysectomized rats exposed to noxious stimuli. Endocrinology 1954;55:28-39.
t i e n t s w i t h h y p e r a d r e n e r g i c states. If t h e s e p a t i e n t s are g i v e n l a b e t a l o l t h e y s h o u l d be o b s e r v e d c a r e f u l l y for increases in b l o o d pressure. If s u c h a c o m p l i c a t i o n ensues, t r e a t m e n t w i t h a pure alpha blocker such as p h e n t o l a m i n e , or a vasodilator such as nitroprusside, diazoxide, or possibly nifedipine, is indicated.
Howard A Bessen, MD, FACEP Department of Emergency Medicine Harbor- UCLA Medical Center Torrance, California 1. Wallin JD, O'Neill WM: Labetaloh Current research and therapeutic status. Arch Intern Med 1983;143:485-490. 2. Wilson DJ, Wallin JD, Vlachakis ND, et ah Intravenous labetalol in the treatment of severe hypertension and hypertensive emergencies. Am JMed 1983;75:95-i02. 3. Briggs RSJ, BirtwelI AJ, PohI JEF: Hypertension response to iabetalol in phaeochromocytoma. Lancet I978;h1045-1046. 4. Feek CM, Earnshaw PM: Hypertensive response to labetaloi in phaeochromocyt0ma. Br Med J 1980;281:387.
Annals of Emergency Medicine
16:8 August 1987