One day as you were looking having a boring shot at your ED job, a 24-year-old male with no significant medical history presented to the you complaining of several hours of substernal chest pain after using cocaine daily for the preceding six days. His last cocaine use was 24 hours prior to presentation He described the chest pain as central,pressure-like,constant and non-radiating. He also reported associated palpitations shortness of breath and diaphoresis, as well as several days of insomnia and anorexia. He had been drinking tequila for the past 24 hours in an effort to “calm himselfdown.”you performed the PE and found :
GENERAL APPEARANCE: appeared well developed and well nourished, anxious and diaphoretic, and in no acute discomfort.
VITAL SIGNS
Temperature 99.1 F(37.3 C)
Pulse 132 beats/minute
Blood pressure 150/92 mmHg
Respirations 24 breaths/minute
Oxygen saturation 98% on room air
Head Eyes & ENT: PERRL, EOMI, dry mucousmembranes.
NECK: Supple, nojugular venous distension.
CARDIOVASCULAR: Tachycardic rate, regular rhythm without rubs,murmurs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender,nondistended.
EXTREMITIES: No clubbing, cyanosis or edema, brisk radial and dorsalis pedis pulses.
SKIN: Warm and moist,no rashes.
NEUROLOGIC: Nonfocal.
you place the patient on the cardiac monitor, a peripheralintravenous line was placed and blood was drawn and sent for laboratory testing.A 12-lead ECG was obtained(Figure given).
tell the differentials diagnosis and your style of proceeding to treat the guy
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15 comments:
RBBB
what exactly :S ?
most probably due to the intake of cocain AND alcohol together, producing a toxic substance called 'cocaethylene', which is rather cardiotoxic. but it is said that it is rather long lasting in the body, n the toxic effect to the brain is more than to the heart...
may be early sign of anterior wall MI as seen by tall t waves in lead v1 and v2.
no.1sarad: can the tall T be a normal variant?
The complaints sound like effects of cocaine.
i would say it's angina pectoris due to consumption of cocaine.
and maybe the ECG doesn't show clear AP due to the alcohol intake?
I think it's most propaply inferior wall myocardial infarction (evolving phase) Vs eschemia(angina during the attack)as there is inverted T wave depression in lead III & aVf (with both infarction & angina) + st segment elevation in leads II,III & aVF
although pathological Q is not so obvious
But we cant relay on severty of symptoms esp. with history of alachol intak.
cardiac treponins + repeated ECG are needed
pain killers & kept under observation
i dun think it's MI.tachycardia,hypertensive, slight feverish, localised,non spreading chest pain, dull pressure-like... although it could be a DDx.do a CE,Trop-I,repeat ECG,then TRO it.
i dorecommend check on the topic of the cocaethylene,it's very interesting))
plus,just read that,it somehow can cause inhibition of K+-channels.n i think this might be the cause of tachycardia,n HPT.
cocaine overdose can cause all the above symptoms, plus the subfebrile temperature. treatment should be symptomatic i think... i have no idea wat's the antidote for it though...
@No.1 Sarah.
how does tall T wave in V1 V2 indicates anterior MI?
wat are the 3 criterias in ECG (although with 2 out of 3 are diagnostic enough) indicating the diagnosis of MI?
A surreptitiously evolving yet of a devastating outcome is the so called cocaine induced MI, it is caused by spasms of the coronaries rather than a usual atherosclerotic lesion in such age group of patients with history of cocaine use. invariably the outcome is the same,, treponins and plcing the patient on an ECG monitor with a look at the electrolytes may be a reasonible approach.. Avoiding beta blockers (used in an attempt to control the elevater HR) is advised as they may precipitate the spasms.
how do we exclude MI here? . . .try thinking of some other differentials too
cocaine overdose has an effect on the heart, brain,lungs, and digective system. it causes tachycardia, hypertension, tachypnea, anorexia, insomnia, and increases body temp. and all of these are the exact signs and symptoms of our patient. now why he has an overdose: 6 days usage of cocaine, so the body is loaded with cocaine metabolites, untill he took alcohol there was no problem but with alcohol intake the metabolic functions of the liver are shut down and cocaine (metabolized by the liver) will increase its effect and we will be in a state of a virtual overdose with a normal cocaine dose.
treatment: is hydration, sedative agents ( to treat the hyperexcitable state, the tachycardia, the tachypnea, and elevation in blood pressure.
in case of increased temp. treat with cool pads, or acetaminophen.
erm.. so when will we get the answer?)
on 23rd when the page will officially start its daily cases and vidos . . we stopped to gather some followers till 23rd Nov
Could be Vasospastic angina (Prinzmetal variant)as Cocaine causes vasospasm...Prinzmetal does produce AMI like changes in ECG (ST Elevation) Should be ruled out with Cardiac biomarkers which are absent in it....Treatment should be the use of a CCB and some otyher vasodilator (B Blocker strictly contraindicated)...Another differential to be checked out is Hypokalemia (T Wave inversion)...If present Should be treated with Calium Gluconate followed by Insulin-Dextrose
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