quizzER Winners:

Chris Guyer            Allison Loynd             Rob Klever

Sam Lee                  Dr Kuhn                     Brian Kern

Marjan Siadat          Julie Nguyen

Devon Moore          Dave Mishkin

Last Week’s Question

The answer is D

Patients with chest pain in the setting of cocaine use should be evaluated for possible myocardial ischemia. Patients suspected of ACS should be managed accordingly with oxygen, nitrates, morphine, aspirin, and benzodiazepines; however, β-adrenergic antagonist therapy is absolutely contraindicated. If β-adrenergic receptors are antagonized, α-adrenergic receptors are left unopposed and available for increased stimulation by cocaine. This may worsen into coronary and peripheral vasoconstriction, hypertension, and possibly ischemia. Therefore, benzodiazepines, which decrease central sympathetic outflow, are the cornerstone in treatment to relieve cocaine-related chest pain.

Check out this articlefrom Annals of Emergency Medicine regarding the use of Beta Blockers and cocaine

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(b) Diltiazem, a calcium channel blocker, can be used in patients with cocaine related chest pain. It is used to lower heart rate. (c) Aspirin should be administered to all patients with chest pain, unless there is a contraindication. In patients with cocaine related chest pain who also seize, aspirin may be held until a CT scan is performed to rule out an intracranial bleed. (a) Phentolamine is a reversible non-selective alpha-adrenergic recceptor antagonist.  The primary application for phentolamine is for the control of hypertensive emergencies, most notably due to pheochromocytoma.  It is also used in cocaine-related hypertension; however, benzodiazepines are favored as it reduces the sympathetic drive leading to a reduction in blood pressure and heart rate. (e) Nitroglycerin should be administered to these patients if they have chest pain. Nitrates dilate the coronary arteries, increasing blood flow to the myocardium.

To learn more about the diagnosis and management of cocaine-related emergencies, click on the image

(from EB Medicine)

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Filed under: quizzER Tagged: | chest pain, cocaine