Podcast 764: Myth or Merit: Beta-Blockers for Cocaine Chest Pain
Release Date: 03/15/2022
Episode 991: BRASH
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls BRASH Syndrome: Bradycardia Renal Failure AV Nodal Blockade Shock Hyperkalemia Clinical Features: Profound bradycardia and shock in patients on AV nodal blockers: Commonly, Beta Blockers or Calcium Channel Blockers Etiology: Caused by an inciting kidney injury: Common triggers include precipitating illness, dehydration, or medications Results in hyperkalemia The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock. ...
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Episode 990: Tramadol, or rather, Trama-don’t
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is tramadol and how does it work? Tramadol is a Schedule IV opioid analgesic used for moderate pain and is often perceived as safer than other opioids due to lower abuse potential. It is a prodrug with weak direct μ-opioid receptor activity. The parent compound also inhibits serotonin and norepinephrine reuptake, giving it SSRI/SNRI-like properties. Tramadol is metabolized by CYP2D6 into O-desmethyltramadol (ODT), which has significantly stronger μ-opioid receptor agonism than the parent drug. What are the concerns with...
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Episode 989: Young Strokes
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: The Case 24F brought in for anxiety. Patient is tearful, not talking, and potentially hyperventilating. History from boyfriend is that she suddenly stopped talking and started crying and it was hard to understand what she was saying. On exam, patient appears anxious and has a gaze preference for the right side and is still having difficulty speaking. Decision is made to stroke alert patient. CT shows early MCA stroke and M2 occlusion. Patient is treated by IR with mechanical thrombectomy. What are the risk factors for strokes in young...
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Episode 988: Infant Botulism
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states All reported cases resulted in hospitalization but no deaths reported to date Infant botulism Occurs when C. botulinum spores germinate in the infant’s intestine, producing toxin Spores are classically found in honey but can also be in dirt or contaminated in infant formula Infants are...
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Carepoint Journal Club: Trauma Discussion
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
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Episode 987: Cough Suppressants
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: OTC Medications Dextromethorphan (DM) Most common OTC cough suppressant Minimal efficacy: Little evidence that it shortens the duration or severity of cough. Potential side effects: At recommended doses: Mild dizziness, drowsiness, GI symptoms Higher doses: Decreased consciousness, dissociative effects Guaifenesin Found in Mucinex and other severe cough/cold products Thins secretions and loosens mucus in airways No more effective than increasing oral fluid intake Prescription Medications Codeine-containing products ...
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Episode 986: Lateral Canthotomy in Emergency Settings
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is orbital compartment syndrome, and how is it assessed in the emergency room? Orbital compartment syndrome (OCS) is an emergent ophthalmic condition in which intraorbital pressure in the orbital compartment rises dramatically, compromising perfusion of the optic nerve and retina, leading to risk of irreversible vision loss. OCS occurs in the context of traumatic lesions with retrobulbar hemorrhage. Intraocular pressures (IOP) are measured via tonometry as a surrogate for intraorbital pressures, with emergent pathology being present when...
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Episode 985: Amiodarone vs. Lidocaine
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How do amiodarone and lidocaine work on the heart? Amiodarone Blocks potassium channels (Class III effect). Also blocks sodium and calcium channels. Additional noncompetitive beta-blocker effects. Stabilizes cardiac tissue, slows heart rate, and suppresses both atrial and ventricular arrhythmias. Lidocaine Blocks fast sodium channels in ventricular tissue (Class Ib). Shortens the action potential in ventricular myocardium, especially in ischemic tissue. Suppresses abnormal automaticity in damaged/irritable myocardium. Which one should...
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Episode 984: Fish Hooks
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Assess first: confirm the hook isn’t near vital structures. Automatic subspecialty consult for eye involvement or proximity to carotid artery, radial artery, peritoneum, testicle, or urethra Barbed hook: cannot be pulled back through the entry without disengaging the barb Removal Techniques String-Pull: best for superficial, single-barbed hooks Depress shank and eye of hook to disengage barb and then pull string taut and jerk suddenly along the long axis Can only be used when the hook is in a body part that can be firmly secured so it...
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Episode 983: Head-of-Bed Position in Large Vessel Occlusion Strokes
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO 0º vs. 30º elevation Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients 45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning Patients in the 30º group experienced worsening of NIHSS by 2 points or more Patients with head position at 0° showed score stability Hazard ratio 34.40; 95% CI,...
info_outlineContributor: Chris Holmes, MD
Educational Pearls:
- Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true?
- 363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study
- 60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk
- Another retrospective cohort study demonstrated no association of negative outcomes with beta-blocker administration in those with a recent positive result on cocaine urine toxicology
- Two more recent meta-analyses were performed finding no association between adverse clinical outcomes and beta-blocker administration for cocaine chest pain
- No prospective randomized-controlled trials have been performed to evaluate the use of beta-blockers for treatment of cocaine chest pain in the ED setting
References
Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use [published correction appears in Ann Emerg Med. 2008 Jul;52(1):90]. Ann Emerg Med. 2008;51(2):117-125. doi:10.1016/j.annemergmed.2007.04.015
Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879. doi:10.1001/archinternmed.2010.115
Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065
Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041
Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644
Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112(12):897-903. doi:10.7326/0003-4819-112-12-897
Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD
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