Regular cocaine use can lead to a bulging weakness in the wall of a branch point of the arteries in the brain. This is often called a berry aneurysm. Eventually this aneurysm bursts, and blood pouring out of the leak is known as a subarachnoid haemorrhage. It can cause major damage to the brain.
In many people this damage can be permanent, leading to difficulty with thought, sight, speech or movement.
Myocardial infarction after cocaine use was first reported in 1982. Since then over 250 cases have been reported, mostly in the United States. We are not aware of any reports from the UK.
A total of 940.7 kg of cocaine with a street value of £ 109.5 million pounds was seized by Her Majesty’s Customs in 1995. Correcting for three large seizures in 1994 this represents an increase of 125% on 1994 figures (personal communication, Press and PR Office, HM Customs and Excise).
We believe these figures put into perspective the potential problems emergency physicians may face in the future. This case highlighted certain areas of difficulty that will be faced by any emergency physician who has to deal with a similar patient, namely:
* Making a precise diagnosis with a limited history.
* The issue ofa/p blockade in cocaine induced myocardial ischaemia.
* The decision to thrombolyse such a patient.
Obtaining the correct history is dependent on maintaining a high index of suspicion and direct questioning is required to make the diagnosis. Other drugs that may cause myocardial ischaemia that we need to inquire about are:
* Amphetamines and their derivatives, which are contained in drugs such as “speed”.
* Caffeine taken as an overdose.
Repeated use of cocaine causes massive stresses and strains on the blood vessels in the coronary arteries and the rest of the body.
This leads to a build- up of cholesterol in the walls of arteries, especially the coronary arteries. A regular cocaine user aged 30 might have blood vessels like a 60-year-old, and this could lead to a sudden and unexpected heart attack in a long-term user.
I have seen patients in their 20s with triple vessel coronary artery disease, and no cause other than cocaine to account for it. One recent piece of U. S. research has shown that a patient with a heart attack is 23 times more likely to have used cocaine very recently.
Some people experience unpleasant crawling feelings under the skin as they are withdrawing from cocaine (‘cocaine bugs’ or ‘snow bugs’). They may describe cocaine bugs as biting, creeping, burning or itching, and may scratch their skin until it bleeds. Although this sensation can be treated to some extent by tranquilliser type drugs, in most cases the user has to wait until it settles down and goes away of its own accord.
A regular cocaine user might suddenly find himself sweating profusely as his body temperature rises dramatically. He pulls his clothes off and tries to cool down with cold water, wet towels or ice. He becomes increasingly agitated, paranoid and confused and might be hallucinating.
He wanders out into the street where this strange, irrational and sometimes vilent behaviour leads to his being restrained by the police. Many peopole with this condition collapse and die while being held down for their own safety.