Acute aortic dissection related to crack cocaine

[Acute aortic dissection. Differential diagnosis of a thoracic emergency]

Acute aortic dissection is an infrequent but important differential diagnosis of acute chest pain. The variability of presenting symptoms makes it difficult to diagnose correctly. Important clinical indicators - besides chest pain - are symptoms related to acute aortic insufficiency and/or pericardial tamponade, variable acute neurologic alterations, or signs of peripheral or visceral malperfusion. The spontaneous prognosis depends on the location and extent of the dissection, and left untreated dissection carries a high mortality. The key goal of preclinical treatment is stabilization with analgesia, mild sedation (opioids, benzodiazepines) and treatment of hypertension (beta-blockers) or hypotension (fluid administration). If the patient presents with a high probability of dissection, early transfer to a specialized center appears advisable. Initial clinical diagnostic studies include transthoracic echocardiogram and computed tomography. If the ascending aorta is involved (Stanford type A) immediate replacement of the proximal aorta is necessary. Isolated dissections of the descending aorta (type B) require aggressive blood pressure control, but can be managed conservatively in most cases. A high level of vigilance is necessary in all patients to detect and treat visceral ischemia.

[Drug addiction and cardiovascular pathologies]

Drug addiction which entails cardiovascular risks unknown or misknown to physicians, currently involves an increasing number of miscellaneous drugs, existing in manifold forms. There appears to be no bounds on the way of intake. All territories of the body may be affected with more or less severity. In young people, the cardiac, coronary, cerebral and peripheral vascular systems are generally involved. Two illicit drugs, cannabis and cocaine, showing a permanent increase in misuse, prevail. This drug addiction comes along with intercurrent pathologies which have their own vascular toxicity, especially HIV infection. Moreover, the advent of new illicit substances emphasizes the complexity of the clinical presentations. These complex situations have a real social and medical impact. We are currently in a phase of permanently increasing risk of cardiovascular complications. The pathophysiological mechanisms involved are intertwined and complicated by the frequent association of polytoxicomania or by the effects excipients added to these drugs: direct vascular toxicity, angeitis, arterial and venous thrombosis. Arsenic, a common component of these drugs, is also found in cigarettes; arsenic toxicity mainly affects the lower limbs. Treatment of these complications is non-specific; the ideal solution being weaning which, unfortunately in this peculiar population of patients, may entail serious complications due to the misuse of substitution products.

Thoracic Aortic Aneurysms

Thoracic aortic aneurysm with dissection is the most common fatal condition involving the aorta. The prevalence of aortic aneurysms appears to be increasing, which may reflect improvements in imaging techniques as well as increased clinical awareness of the condition. Most thoracic aortic aneurysms are caused by atherosclerosis and its associated risk factors of hypertension, smoking, and hypercholesterolemia. The clinical presentation varies and may mimic other more common disease processes. Early recognition on the basis of a focused history, physical examination, appropriate diagnostic studies, and management is essential for good outcomes.

Anesthetic management of the illicit-substance-using patient

PURPOSE OF REVIEW

During the last few years, drug abuse has risen to the point that almost 20 million Americans are current abusers of illicit substances. These patients present to us as anesthesiologists in a variety of circumstances: in obstetrics for labor and emergencies, in trauma for emergency surgeries or life-saving (resuscitative) situations and in everyday elective surgeries. Therefore it is important for anesthesiologists to know about the most common illicit drugs being used, to know their side effects and clinical presentation if abused or intoxicated, and to know what anesthetic options would be beneficial or detrimental.

RECENT FINDINGS

In this article we will review some of the most commonly used illicit drugs, their effects on the organ systems and some tips to take into consideration when providing anesthesia for these patients. We will discuss marijuana, cocaine, opioids, hallucinogens, solvents and the newer so-called rave or club drugs. Newer treatment options for opioid detoxification will also be discussed.

SUMMARY

Illicit substance abuse is a major health concern in the United States. Drug use, either acute or chronic, has potentially grave consequences which include changes affecting the pulmonary, cardiovascular, nervous, renal and hepatic systems. Anesthesiologists come into contact with these patients in emergency and everyday situations. Due to the diverse clinical presentations that may arise from single substance or polysubstance abuse, anesthetic management should be tailored to each individual and universal precautions should always be followed when providing care.

Cocaine induces apoptosis in primary cultured rat aortic vascular smooth muscle cells: possible relationship to aortic dissection, atherosclerosis, and hypertension

Cocaine abuse is known to induce many adverse cardiovascular effects, including hypertension, atherosclerosis, and aortic dissection. A major physiological event leading to these pathophysiological actions of cocaine could be apoptosis. This study was designed to investigate if primary cultured rat aortic vascular smooth muscle cells (VSMCs) can undergo apoptosis when treated with cocaine. After treatment with cocaine (10(-6) to 10(-4) M), morphological analysis of aortic VSMCs using confocal fluoresence microscopy showed that the percentage of apoptotic aortic VSMCs increased after cocaine (10(-6) to 10(-4) M) treatment for 12, 24, and 48 h. These results demonstrate that aortic VSMCs can undergo rapid apoptosis in response to cocaine in a concentration-dependent manner. Cocaine-induced apoptosis may thus play a major role in cocaine abuse-induced aortic dissection, atherosclerosis, and hypertension.

Aortic disasters

TAD and AAA are two of the highest risk disease entities in emergency medicine. Emergency physicians should be vigilant in their approach to patients who have symptoms compatible with acute aortic disease. In chest and abdominal pain presentations, the chart must look like there was a search for the TAD and AAA. By having a sound knowledge of atypical cases;, having an appreciation for how subtle TAD and AAA can be; and recording and documenting a thorough history, physical examination, and risk factor profile, the emergency physician may reduce substantially the risk of missing a diagnosis and subsequently being sued. Emergency physicians cannot diagnose every case of acute aortic disease; what they can do is practice with a sound understanding of risk management principles and consider these diagnoses in all patients with chest, back, or abdominal pain.Ultimately, this strategy would provide protection for the patient and the physician.

Thoracic aortic dissection associated with cocaine abuse

Cardiovascular complications of cocaine abuse include myocardial ischemia and infarction, dysrhythmias, cardiomyopathies and aortic dissection. The case in point pertains to a 26-year-old, Caucasian male, substance abuser who suffered a thoracic aortic dissection following the use of crack cocaine. The autopsy and histological findings showed a connective tissue abnormality including a focal microcystic medial necrosis and a fragmentation of the elastic fibers in the arterial walls. Blood concentrations of cocaine and benzoylecgonine, taken individually, were considered to be within a potentially toxic range. Blood concentrations of methadone also indicated use of this drug at the same time. The small amounts of morphine found in the blood and urine were compatible with heroine or morphine use more than 24 h before death.

Aortic emergencies

Prompt recognition of actual or impending aortic emergencies is essential to the effective practice of emergency medicine. Understanding the pathophysiologic principles and awareness of the potential subtleties in the clinical presentations of aortic dissection, aneurysm, and occlusive disease are prerequisites to this task. Knowledge of current diagnostic modalities is also important if these entities are to be identified rapidly and managed efficiently to maximize the potential for a good patient outcome. Awareness of the potential complications of these conditions and the necessary interventional and resuscitative measures that might be called for in the appropriate clinical setting are likewise essential requirements for the EP. Appropriate surgical consultation and mobilization of operative resources form the backbone of appropriate management in the patient who has an aortic emergency.

Cardiovascular manifestations of substance abuse part 1: cocaine

Substance abuse with cocaine is associated with multiple cardiovascular conditions, including myocardial infarction, dissection, left ventricular hypertrophy, arrhythmias, sudden death, and cardiomyopathy. Cocaine has effects to potentiate the physiologic actions of catecholamines and has direct effects on voltage-dependent sodium ion channels related to local anesthetic properties. The effects of cocaine can be augmented with concomitant alcohol consumption. Acute myocardial ischemia caused by cocaine may be related to in situ thromboisis and/or coronary vasospasm. Treatment strategies for cocaine-induced myocardial infarction would include antiplatelet therapy, thrombolysis, and vasodilators (eg, nitrates, nifedipine). Beta-adrenergic blockers should not be used unless concomitant vasodilator therapy is given.