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The Case of the Comatose Prisoner James Roberts, MD The Medical College of Pennsylvania/ Hahnemann University Drexel University School of Medicine Mercy Catholic Medical Center Philadelphia, Pennsylvania. Case.

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The Case of the Comatose PrisonerJames Roberts, MDThe Medical College of Pennsylvania/ Hahnemann UniversityDrexel University School of MedicineMercy Catholic Medical CenterPhiladelphia, Pennsylvania


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Case

A 28 y/o suspected cocaine dealer was involved in a police chase that ended with the suspect’s car ramming a pole. The extrication took 30 minutes due to significant vehicle damage. The man was awake at the scene and was taken to a hospital for evaluation.


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Case

At the hospital he had a pulse of 110/min but otherwise normal vital signs and no complaints. Other than a facial abrasion and a small scalp hematoma, the physical examination was normal. In the ED he was agitated and urinated on the floor of the examining room (“I couldn’t hold it”).


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Case

No laboratory tests or X rays were performed. He was observed for 2 hours, “remained stable,” and was discharged into police custody at 9pm with a diagnosis of “minor soft tissue injuries.” At the jail he was placed in a cell with 3 other prisoners. At 8am he was unarousable and was returned to the hospital.


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Case

  • Upon arrival:

    • Temp: 97.4 R

    • BP: 124/60

    • Pulse: 78/min

    • Resp: 16/min

    • POx 99% on RA

  • Monitor: sinus rhythm

  • He was incontinent of urine

  • Differential diagnosis at this juncture?


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Differential Diagnosis

  • Head trauma

  • CVA

  • Hypoglycemia/Hyperglycemia

  • Drug Overdose (body packer, additional ingestion in jail)

  • Post Ictal

  • Malingering

  • Wernicke’s encephalopathy

  • Sepsis, CNS infection, hepatic coma, hypernatremia


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Further History:

  • No old records available

  • No answer at home phone

  • Police clueless

  • Previous ED visit confirmed

  • Next step: further evaluation/treatment


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Further Examination

  • Facial injury/scalp hematoma

  • No Battle’s sign/ no hemotympanum

  • Abdomen/chest/extremities demonstrated no abnormality

  • No other signs of trauma

  • No sign of IVDA

  • Body habitus of chronic cocaine use

  • What are the key components of the neurologic examination?


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Neurologic Examination

  • No response to deep pain/no posturing

  • Pupils: 2-3 mm and sluggish

  • Dysconjugate gaze present

  • No gag reflex

  • Flaccid extremities/no reflexes elicited

  • Negative Babinski sign, no clonus, no fasciculations

  • Outline the Basic Initial Treatment


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Initial Basic Treatment

  • Safety net: IV, Oxygen, monitor, pulse ox, dynamap

  • Dextrostick: glucose 110

  • Foley catheter: clear urine

  • ABG: pH 7.43; PO2: 145 torr on 2 liters; PCO2 42 torr; HCO3: 23

  • Intubated for airway protection

  • Note: no response to above procedures, including intubation

  • What definitive tests are required at this juncture?


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Results of Tests:

  • Head CT scan: negative

  • CBC, Electrolytes, BUN/CR, PT/PTT : Normal Urine drug screen: (+) cocaine, (-) for barbs, benzo, opiates

  • Serum ethanol : 10 mg%

  • Lumbar puncture: normal opening pressure, neg chemistry/no cells

  • EKG: Normal

  • Liver function/ammonia: normal

  • What therapies are reasonable?


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Therapy: Probably Warranted

  • Small dose naloxone, charcoal, thiamine

  • Toxicology/poison center consultation

  • Neurology consultation

  • ICU admission


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Therapy: Probably Not Warranted

  • Flumazenil

  • Gastric lavage/WBI

  • Antibiotics

  • MRI


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Hospital Course

  • Admitted to the ICU. Over the next 12-16 hours the patient slowly woke up, was extubated, and admitted to a 2-week crack cocaine binge, but denied other drugs. He related numerous such “crashes” when he ran out of money for cocaine.

  • DIAGNOSIS: The cocaine washout syndrome


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Pathophysiology of the Cocaine Washout Syndrome

  • Most likely a lack of CNSneurotransmitters

    • Norepinephrine

    • Serotonin

    • Dopamine


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Incidence/Clinical Caveats

  • Incidence unknown, likely quite common

  • No data in the medical literature, but street knowledge

  • Occurs when drug use halted (medical illness, jail, insolvent)

  • Precipitated in ED with minimal benzodiazepine administration

  • Vital signs normal, usually not hypotensive, bradycardic

  • Signs of cocaine toxicity absent

  • Patients appear in a deep sleep state

  • Nonresponsiveness may be quite impressive


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Clinical Approach

  • Diagnosis

    • Clinical diagnosis/rule out other conditions

    • No known value of catecholamine level

    • Urine positive for cocaine

    • May require extensive, expensive R/O workup

  • Treatment

    • Supportive only/protect airway and vital signs

    • Stimulants not warranted

  • Course

    • Patients wake up slowly over 12-24 hours


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