Rosen & Barkin's 5-Minute Emergency Medicine Consult (164 page)

• Diazepam: 5 mg incremental doses IV
  
• Lorazepam: 2 mg incremental doses IV
  

• Activated charcoal slurry: 1–2 g/kg up to 90 g PO
  
• Dextrose: D
  ₅₀
  W 1 ampule (50 mL or 25 g) (peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Esmolol: 50–200 μg/kg/min IV infusion titrated to effect
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg up to 2 mg) IV or IM initial dose
  
• Nitroglycerin: 10–100 μg/min IV infusion
  
• Nitroprusside: 0.3 μg/kg/min IV (titrate to effect up to 10 μg/kg/min)
  
• Phentolamine: 5 mg IV q15–24min (titrate to clinical effect)
  
• Polyethylene glycol (GoLYTELY): 1–2 L PO/hr until packet passage (efficacy controversial)
  

FOLLOW-UP

• Altered mental status
  
• Abnormal vital signs: Heart rate >100 bpm, diastolic BP >120 mm Hg, or hypotension
  
• Hyperthermia
  
• Cocaine-induced myocardial ischemia
  
• Body stuffers and body packers
  
• ICU admission for moderate to severe toxicity
  

• Mental status and vital signs normal after 6 hr of observation
  
• Body packers or stuffers with confirmed expulsion of packets and no clinical signs of toxicity
  
• Stuffers may be discharged if uncomplicated packets were ingested and if asymptomatic for 12–24 hr.
  

• Benzodiazepines are the 1st-line treatment for the sympathomimetic toxidrome from cocaine.
  
• Avoid β-blockers in the hyperdynamic cocaine intoxicated patient.
  
• Consider a broad differential in cocaine-associated chest pain.
  
• An abdominal flat plate radiograph will be of some value in a body packer, but of no value in imaging packets in a body stuffer.
  

• Hoffman RS. Cocaine. In: Goldfrank LR, ed.
  Goldfrank’s Toxicologic Emergencies
  . 9th ed. Stamford, CT: Appleton & Lange; 2010:1091–1102.
  
• Jones JH, Weir WB. Cocaine-associated chest pain.
  Med Clin North Am
  . 2005;89:1323–1342.
  
• June R, Aks SE, Keys N, et al. Medical outcome of cocaine bodystuffers.
  J Emerg Med
  . 2000;18:221–224.
  
• Kalimullah EA, Bryant SM. Case files of the medical toxicology fellowship at the Toxikon Consortium in Chicago: Cocaine-associated wide-complex dysrhythmias and cardiac arrest-treatment nuances and controversies.
  J Med Toxicol
  . 2008;4:277–283.
  

CODES

970.81 Poisoning by cocaine

BASICS

• Trauma that perforates the colon inflames the cavity in which it lies.
  
• Peritoneal inflammation from hollow viscus perforation often requires hours to develop.
  
• Mesenteric tears from blunt trauma cause hemorrhage and bowel ischemia.
  
• Delayed perforation from ischemic or necrotic bowel may occur.
  
• Peritonitis and sepsis may develop from the extravasated intraluminal flora.
  
• Ascending and descending colon segments are retroperitoneal.
  
• The left colon has a higher bacterial load than the right.
  
• Morbidity and mortality increase if the diagnosis of colon injury is delayed.
  

• Penetrating abdominal trauma:
  
  • The colon is the 2nd most commonly injured organ in penetrating trauma.
    
  • Gunshot wounds have the highest incidence.
    
  • Transverse colon is most commonly injured.
    
  • Often presents with peritonitis
    
• Blunt abdominal trauma:
  
  • Colon rarely injured in blunt trauma
    
  • Burst injury occurs from compression of a closed loop of bowel.
    
  • Intestine may be squeezed between a blunt object (lap belt) and vertebral column or bony pelvis.
    
  • Sudden deceleration may produce bowel–mesenteric disruption and consequent devascularization.
    
  • With deceleration, the sigmoid and transverse colon are most vulnerable.
    
• Transanal injury:
  
  • Iatrogenic endoscopic or barium enema injury
    
  • Foreign bodies used during sexual activities may reach and injure the colon.
    
  • Compressed air under high pressure such as at automobile repair facilities can perforate the colon even if the compressor nozzle is not fully inserted anally.
    
  • Swallowed sharp foreign bodies (toothpick) may penetrate the colon, particularly the cecum, appendix, and sigmoid:
    
    • Most foreign bodies pass without complications.
      

Unlike adults, children have an equal frequency of blunt and penetrating colon injuries.

DIAGNOSIS

• Colon trauma is generally associated with other intra-abdominal and extra-abdominal injuries, commonly to the small intestine.
  
• Injuries of significant severity may have minimal early findings.
  
• It is uncommon to determine specific organ injury on physical exam.
  
• Assess on exam:
  
  • Abdomen for peritoneal signs
    
  • Ecchymosis or hematoma on lower abdomen from lap-belt compression
    
  • Ecchymosis on epigastric region from steering-wheel compression
    
  • Grey Turner sign (flank hematomas) resulting from retroperitoneal bleeding.
    
  • Foreign bodies or blood on digital rectal exam (be careful if sharp object suspected)
    
  • Note: Abdominal wall ecchymosis or hematoma is not always present despite existing injury.
    
  • Note: Bowel sounds are not helpful.
    

• Serial abdominal exam because inflammation takes time to develop
  
• Abdominal CT with contrast is the best diagnostic study in stable patients.
  
• US and diagnostic peritoneal lavage (DPL) are helpful in the potentially unstable patient.
  

• No individual test or combination of currently available diagnostic modalities is adequate to exclude blunt colonic injury.
  
• Signs of peritoneal irritation owing to intestinal injury typically develop hours after the event.
  

• Electrolytes
  
• Calcium, magnesium
  

• CT is more useful for detecting penetrating vs. blunt colon injury.
  
• CT with triple contrast allows intraperitoneal and retroperitoneal visualization.
  
• Oral contrast is not essential in blunt abdominal trauma CT evaluation.
  
• Although CT may miss colon injuries, abnormal findings are typical.
  
• CT is only moderately sensitive at identifying hollow viscus injury.
  
• Hollow viscus injury–associated CT findings include extraluminal gas or contrast, mesenteric fat streaking, and free fluid without solid organ injury.
  
• Water-soluble enema with fluoroscopy is useful if other test results are inconclusive.
  
• Plain abdominal radiographs can show indirect signs such as intraperitoneal and retroperitoneal free air.
  
• FAST US exam does not evaluate for enteric injury and retroperitoneal hemorrhage.
  
• See “Abdominal Trauma, Blunt”; “Abdominal Trauma, Imaging.”
  

• DPL or ultrasound in addition to CT will increase sensitivity.
  
• In blunt trauma, DPL will often not detect retroperitoneal injuries and enteric injury as intra-abdominal bleeding is limited.
  
• Fecal or vegetable material on DPL analysis indicates hollow viscus injury.
  
• Lavage white cell response may be negative secondary to delayed peritoneal inflammation.
  
• In hollow viscus injury, lavage WBC count: RBC ratio is higher than that seen with solid organ injuries.
  

• Other intra-abdominal injuries
  
• A fractured pelvis may present similarly to intraperitoneal injuries in children.
  

TREATMENT