Illegal Drugs - What affect on the EKG, the 12 lead?

[Doczilla]

Chronic cocaine use leads to accelerated atherosclerosis and hypertension, and acute use can lead to rhabdo and hypercoagulability. Cocaine users can have thrombotic events, just like everyone else, and at young ages. It's generally a bad idea to dismiss cocaine-associated ST elevation as "just vasospasm". They should go to cath like everyone else.

'zilla

[Camulos]

Cocaine users can have thrombotic events, just like everyone else, and at young ages. It's generally a bad idea to dismiss cocaine-associated ST elevation as "just vasospasm". They should go to cath like everyone else.

'zilla

Agree 100%. I guess it's one of those cases where a presumptive diagnosis is made based on likelihood and you have to go with the numbers until proven otherwise. In that sense should be treated as standard MI if the S+S are there.

I noticed an earlier respondent advocated benzo's and CCB's if cocaine induced MI is the culprit. Would any one have used beta blockers for rate control in this scenario?

Stay safe,

Curse

[Camulos]

There is a theoretical problem with aggressive beta blockade and increasing hypertension due to unopposed alpha blockade.

Sorry missed that my question on beta blockers had been answered earlier.

Here's a link on this topic that may be useful

http://circ.ahajournals.org/cgi/reprint/117/14/1897

Go to the section that states BEGIN DOWNLOAD and you can then access the article

Stay Safe,

Curse

[spenac]

BP was around 150/100. Patients rate dropped to about 115 with vagal. Pain was 9/10. By hospital about 3/10.

Never found out drug screen. They did ship him to a large hospital with a cath lab though.

The part that threw me was that they were saying was not MI but just a reaction to the illegal drugs. I mean the way I see it if it looks like a duck, quacks like a duck, its a duck, but asically they said it was a chicken. Hope that illustrates how I was feeling about that one.

Patients PCR already sent in so could not get 12 lead for you guys. Seems V2-V5 were elevated, II,III, aVF, depressed, but I may be confused as I've been wearing out the 12 lead.

Thanks for all the help. As a student as well as being allowed to operate at the Paramedic level I sometimes still get a little lost.

[FL_Medic]

Did you do your 12-lead before or after HR dropped? That rate could have caused ischemia itself, and if the doc had a patient with a low sinus tach, the elevation may not have been present. Also your nitrates could reversed ECG changes. My first thought though is that you had a patient with early repolarization.

What monitor did you use? Did it diagnose ********Acute MI*********? With minimal artifact, modern monitors are pretty damn good at diagnosing AMI with ST-elevation > 1mm.

With the changes you noted though, I would say you had a STEMI patient. We don't screen in the field, and even if we did, you should treat the same way initially. Maybe with the addition of a benzo. Cocaine can induce an MI, not a clot, but still warrants some O2, pain control, and vasodilation. Your treatment was dead on. Your question is a good one. Sometimes doctors (like paramedics) get one or two calls that present similarly and make there initial diagnosis without using diagnostic equipment. Not saying this is the case, but sounds like he made a pretty presumptuous comment.

[care a medic]

On a recent call I had a patient with obvious st elevation and depression in continous and reciprical leads. At the hospital the doctor said he thought patient was on illegal drugs and that he was not having an MI. Patient was under 40 with severe chest pain. Ran the full MONA by time at hospital. My question is what should I look for different on my EKG or 12 lead that might indicate drug use rather than MI. Doctor could not explain to me why and the drug screen had not returned prior to leaving hospital. Dr mention crack and a couple of other drugs that he suspected. Pupils were equal and reactive normal pupil size to.

Thanks for helping in advance. Please don't just say stupid Doctor if that is your only thought. I want facts or real possibilitys. Thanks.

My opinion: treat the patient-not the monitor(per se). Usually, when the patient has taken crack, his HR is tachycardic and BP WNL. the EKG may also be normal. Just look at the patient and the history he gives you, and you will probably pick up on it 90% of the time.

I'm not trying to be a smart-butt with my first statement. I've come across many substance abuse cases and I basically treat them with what is presented. Most of the time, they aren't going to admit to drug usage, until you get to the ED-maybe. They just do not want to tell the medic. They feel more comfortable telling the Doc because of patient confidentiality(?), and feel the medic will tell law enforcement whether they(LE) are on the scene or not.

I hope this helped! Stay safe!

[spenac]

Did you do your 12-lead before or after HR dropped? That rate could have caused ischemia itself, and if the doc had a patient with a low sinus tach, the elevation may not have been present. Also your nitrates could reversed ECG changes. My first thought though is that you had a patient with early repolarization.

What monitor did you use? Did it diagnose ********Acute MI*********? With minimal artifact, modern monitors are pretty damn good at diagnosing AMI with ST-elevation > 1mm.

With the changes you noted though, I would say you had a STEMI patient. We don't screen in the field, and even if we did, you should treat the same way initially. Maybe with the addition of a benzo. Cocaine can induce an MI, not a clot, but still warrants some O2, pain control, and vasodilation. Your treatment was dead on. Your question is a good one. Sometimes doctors (like paramedics) get one or two calls that present similarly and make there initial diagnosis without using diagnostic equipment. Not saying this is the case, but sounds like he made a pretty presumptuous comment.

I don't use the monitor diagnosis as they tend to be unreliable. Got 3 12 leads. Elevation and depression present everytime.

[FL_Medic]

I don't use the monitor diagnosis as they tend to be unreliable. Got 3 12 leads. Elevation and depression present everytime.

Actually the monitor diagnosis for Acute MI is pretty accurate if artifact is minimal. The rhythm diagnosis is, however, unreliable. If your have the Acute MI diagnosis, I would be very skeptical to say it wasn't. Although it is more likely to diagnose an MI when it is not one than it is to miss an AMI. If you see an MI and the monitor doesn't diagnose it, look again. I'm not saying it isn't, but it warrants a second look.

[Arizonaffcep]

Actually the monitor diagnosis for Acute MI is pretty accurate if artifact is minimal. The rhythm diagnosis is, however, unreliable. If your have the Acute MI diagnosis, I would be very skeptical to say it wasn't. Although it is more likely to diagnose an MI when it is not one than it is to miss an AMI. If you see an MI and the monitor doesn't diagnose it, look again. I'm not saying it isn't, but it warrants a second look.

But it should always be reviewed by a person who knows how to read them...CEP, MD, RN, whomever to be able to give an advanced notice for the ED and the cath lab. But...keep in mind, it CANNOT RULE OUT MI...for that, blood work is needed.

[Vodcox]

I was always led to believe that Cocaine use was one of the causes of Prinzmetal's Angina.

http://en.wikipedia.org/wiki/Prinzmetal's_angina

Still right to treat as MI

Edit: More here...

http://content.nejm.org/cgi/content/full/349/1/e1

I was also taught this