SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Cocaine washout syndrome (CWS) is a rare complication caused by prolonged cocaine use, manifested by brief coma that resolves spontaneously. The proposed mechanism is depletion of adrenergic neurotransmitters due to prolonged and persistent stimulation. There are only 3 cases reported in the literature and the incidence of this syndrome is unknown. Here, we report an unusually extreme case of CWS presenting with coma and refractory shock.
CASE PRESENTATION: A 33-year-old African-American woman with history of chronic cocaine abuse was brought to the emergency department unresponsive. The patient was last seen “stoned” [sic] by her mother 6 hours prior to arrival. She was given naloxone in the field with no improvement in mental status. In the ED, vital signs showed hypotension (61/24mmHg), tachycardia (132bpm), hypoxia (90% on ambient air) and hypothermia (33.9°C). Physical examination revealed a comatose patient with GCS of 3, covered in vomit, with sluggishly reactive non-dilated pupils, no gag, cough or corneal reflexes and no nystagmus. The patient was intubated for airway protection. Chest radiograph and head CT were normal while lab results showed acute kidney injury, increased liver enzymes up to 1000s, leukocytosis, respiratory and anion gap metabolic acidosis with pH 7.08, pCO2 48mmHg, HCO3 12mmol/L and lactate of 64mg/dL. Urine toxicological screening was positive for cocaine, benzodiazepines, opioids and PCP, while blood analyses were negative for alcohol, acetaminophen, salicylates and serum osmolar gap. Despite aggressive fluid resuscitation and 3 pressors at maximal infusion rates, she remained hypotensive and anuric. Stress dose steroids and antibiotics were empirically started. However, only 8 hours after admission, she regained brainstem reflexes. Hemodynamic status also dramatically improved and pressors were being successfully weaned. The following day, she was off pressors, mental status returned to baseline and she was ready to resume spontaneous ventilation. As blood cultures and cosyntropin test were negative, antibiotics and steroids were discontinued. After being extubated on day 2, she admitted to daily cocaine use for several months, with a binge episode on the day of admission. After psychiatry was consulted and ancillary support was set up, she was discharged home in a stable condition. [Image1]
DISCUSSION: CWS remains a diagnosis of exclusion in patients with corroborative history and high clinical suspicion. Differential diagnoses are listed in table1.
CONCLUSIONS: This case outlines a rare but potentially fatal complication of acute cocaine intoxication in chronic cocaine users. Patients should be admitted to the appropriate level of monitoring ; i.e. intensive care unit. Aggressive fluid resuscitation with meticulous hemodynamic and ventilatory support is the cornerstone of management in cocaine washout syndrome.
1) Cocaine washout syndrome, Greenberg MI, Roberts JR, Ann of Int Med, 2000 Apr18;132(8):679-80
DISCLOSURE: The following authors have nothing to disclose: Ji Hyun Rhee, V. Sandeep Yadavalli, Parit Mekaroonkamol, Rene Franco, K. Randall Young, Adam Rowden
No Product/Research Disclosure InformationInternal Medicine, Albert Einstein Medical Center, Philadelphia, PA