Patients with detectable cocaethylene are more likely to require intensive care unit admission after trauma

Wiener, Sage E.; Sutijono, Darrell; Moon, Cynthia H.; Subramanian, Ramanand A.; Calaycay, Jim; Rushbrook, Julie Ivory; Zehtabchi, Shahriar

doi:10.1016/j.ajem.2009.06.014

Cited by 39 publications

(19 citation statements)

References 22 publications

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“…Before this study, pre-injury cocaine use has not been established as a significant predictor of outcomes following trauma (16-19, 21). However, a combination of cocaine and ethanol yields the toxic metabolic cocaethylene, which has been significantly associated with increased ICU admission (20). In the present study, cocaine use was associated with longer ICU LOS after adjusting for differences in patient characteristics, but this effect was not significantly impacted by concurrent alcohol use.…”

Section: Discussionmentioning

confidence: 99%

The impact of pre-injury controlled substance use on clinical outcomes after trauma

Cheng

Inaba

Johnson

et al. 2016

Journal of Trauma and Acute Care Surgery

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Background A disproportionately high percentage of trauma patients use controlled substances, and they often co-ingest multiple drugs. Previous studies have evaluated the effect of individual drugs on clinical outcomes following trauma. However, the impact of all drugs included in a comprehensive screening panel has not yet been compared in a single cohort of patients. Methods All trauma patients who underwent urine drug screens following admission to the LAC+USC Medical Center (01/2008-06/2015) were identified retrospectively. Univariable and multivariable regression analyses determined the significance of all drugs tested in the hospital’s standard toxicology screen (amphetamine, barbiturate, benzodiazepine, cocaine, opiate, phencyclidine) on clinical outcomes. Results A total of 10,288 patients who underwent admission toxicology screening were identified. While 5,661 patients had completely negative screens, 3,370 patients tested positive for only one drug and 1,257 patients tested for multiple drugs. Univariable analysis indicated that patients who tested positive for multiple drugs had higher rates of operative intervention (p<0.001), longer hospital stay (p<0.001), and longer ICU stays (p<0.001). Multivariable analysis indicated that phencyclidine was associated with higher rates of mortality (p=0.028) while amphetamine was associated with lower rates of mortality (p=0.008). Higher rates of operative intervention were observed in patients testing positive for amphetamine (p<0.001), benzodiazepine (p<0.001), or opiate (p<0.001). Benzodiazepine use was associated with higher rates of mechanical ventilation (p<0.001), but use of amphetamines (p=0.030) or opiates (p<0.001) was associated with lower rates. Conclusions Pre-injury use of amphetamine, barbiturate, benzodiazepine, cocaine, opiate, and PCP have significant and variable impact on clinical outcomes following trauma. Comparing the relative effect of each drug class can help clinicians risk-stratify all trauma patients, including those who test positive for multiple substances.

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Section: Discussionmentioning

confidence: 99%

The impact of pre-injury controlled substance use on clinical outcomes after trauma

Cheng

Inaba

Johnson

et al. 2016

Journal of Trauma and Acute Care Surgery

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“…The combination of EtOH and cocaine heightens the effects of both substances, prolongs the agitation and paranoia induced by cocaine and contributes to the toxicity associated with excessive consumption 8. Also, it has been proven that the presence of cocaethylene in urine increases five times the risk of requiring assistant care at the Intensive Care Unit (ICU) 9. Human experiments have shown that the use of cocaine increases the cardiovascular response with higher heart rate (HR) and blood pressure (BP); EtOH increases HR and decreases BP, while co-consumption increases the HR by four times 10…”

Section: Introductionmentioning

confidence: 99%

<p>Cocaine, ethanol, cannabis and benzodiazepines co-consumption among patients assisted at the emergency room</p>

Teherán

Ospina

Cadavid

et al. 2019

OAEM

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IntroductionCocaine and ethanol (EtOH) co-consumption is a risk factor for physiologically and clinically negative outcomes. We describe the occurrence of cocaine consumption alone or co-consumption with EtOH and others psychotropics.Patients and methodsThe descriptive research used data on medical records of patients positive to cocaine test who attended an emergency room between 2016 and 2017. We determined the frequency of cocaine consumption alone and co-consumption with EtOH, cannabis or benzodiazepines (BZDs).ResultsOver one year period, 88 patients (13.3%) were positive to cocaine test, mainly attended on weekends, in holiday months, young adults or men. Among those positive for cocaine, 72% were also positive for EtOH, cannabis or BZD. Cocaine co-consumption with one or two out of three substance was 55.2% (CI95%; 44.7-65.8%) and 16.4% (CI95%;8.58-24.3%), respectively. Co-consumption was more frecuently wih EtOH, followed by cannabis or BZD. ConclusionCo-consumption of cocaine with EtOH is very common and could be associated with acute or chronic consumption of cannabis or acute exposure to BZDs. It is important that emergency physicians use a systematic approach to diagnose and treat more than one psychotropic substance in cocaine positive patients.

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“…1 Co-intoxication slows clearance of cocaine, 6,7 produces the cardio-toxic metabolite cocaethylene, 8,9 and increases the likelihood of hospitalization. 10 …”

Section: Introductionmentioning

confidence: 99%

Cardiac Depression Induced by Cocaine or Cocaethylene Is Alleviated by Lipid Emulsion More Effectively Than by Sulfobutylether‐β‐cyclodextrin

Fettiplace

Pichurko

Ripper

et al. 2015

Academic Emergency Medicine

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Objectives Cocaine intoxication leads to over 500,000 emergency department visits annually in the USA and ethanol co-intoxication occurs in 34% of those cases. Cardiotoxicity is an ominous complication of cocaine and cocaethylene overdose for which no specific antidote exists. Because infusion of lipid emulsion (Intralipid) can treat lipophilic local anesthetic toxicity and cocaine is an amphipathic local anesthetic, the authors tested whether lipid emulsion could attenuate cocaine cardiotoxicity in vivo. The effects of lipid emulsion were compared with the metabolically inert sulfobutylether-β-cyclodextrin (Captisol) in an isolated heart model of cocaine and cocaethylene toxicity to determine if capture alone could exert similar benefit as lipid emulsion which exhibits multi-modal effects. The authors then tested if cocaine and cocaethylene, like bupivacaine, inhibit lipid-based metabolism in isolated cardiac mitochondria. Methods For whole animal experiments, Sprague-Dawley rats were anesthetized, instrumented, and pretreated with lipid emulsion followed by a continuous infusion of cocaine to assess time of onset of cocaine toxicity. For ex vivo experiments, rat hearts were placed onto a non-recirculating Langendorff system perfused with Krebs-Henseleit solution. Heart rate, left ventricle maximum developed pressure (LVdevP), left ventricle diastolic pressure (LVDP), maximum rate of contraction (+dP/dtmax), maximum rate of relaxation (−dP/dtmax), rate-pressure product (RPP = heart rate*LVdevP), and line pressure were monitored continuously during the experiment. A dose-response to cocaine (10, 30, 50, and 100 μM) and cocaethylene (10, 30, 50 μM) was generated in the absence or presence of either 0.25% lipid emulsion, or sulfobutyl-β-cyclodextrin. Substrate-specific rates of oxygen consumption were measured in interfibrillar cardiac mitochondria in the presence of cocaine, cocaethylene, ecgonine, and benzoylecgonine. Results Treatment with lipid emulsion delayed onset of hypotension (140 seconds vs. 279 seconds p = 0.008) and asystole (369 seconds vs. 607 seconds; p = 0.02) in whole animals. Cocaine and cocaethylene induced dose-dependent decreases in RPP, +dP/dtmax, and −dP/dtmaxabs (p < 0.0001) in Langendorff hearts; line pressure was increased by cocaine and cocaethylene infusion, but not altered by treatment. Lipid emulsion attenuated cocaine- and cocaethylene-induced cardiac depression. Sulfobutyl-β-cyclodetrin alone evoked a mild cardio-depressant effect (p < 0.0001) but attenuated further cocaine- and cocaethylene-induced decrements in cardiac contractility at high concentrations of drug (100 μM; p < 0.001). Finally, both cocaine and cocaethylene, but not ecgonine and benzoylecgonine, inhibited lipid-dependent mitochondrial respiration by blocking carnitine exchange (p < 0.05). Conclusions A commercially available lipid emulsion was able to delay progression of cocaine cardiac toxicity in vivo. Further, it improved acute cocaine- and cocaethylene-induced cardiac toxicity in rat isolated heart whil...

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Patients with detectable cocaethylene are more likely to require intensive care unit admission after trauma

Cited by 39 publications

References 22 publications

The impact of pre-injury controlled substance use on clinical outcomes after trauma

The impact of pre-injury controlled substance use on clinical outcomes after trauma

<p>Cocaine, ethanol, cannabis and benzodiazepines co-consumption among patients assisted at the emergency room</p>

Cardiac Depression Induced by Cocaine or Cocaethylene Is Alleviated by Lipid Emulsion More Effectively Than by Sulfobutylether‐β‐cyclodextrin

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