A 42 y.o. male is found outside in August unresponsive

He presents altered, hypotensive and bradycardic.

what else do you notice on his EKG?

Even though it was August in St. Louis;  our patient presented with hypothermia and a temp of 33. The EKG  demonstates first degree and second degree AV block with a failed atrial beat.  He also had Osborn wave  appearing at the end of the QRS.  These abnormalities disappeared as he was rewarmed.

Hypothermia is defined as a temp less than 35 degrees. 

degrees of hypothermia

At the start of hypothermia a stress reaction is induced, resulting in sinus tachycardia, although bradycardia ensues as the temperature drops.  Varying degrees of heart block can also be seen along with a fib, and severe sinus bradycardia . 

BUT OUR PATIENT HAD ANOTHER PROBLEM

 In addition to sleeping outside in the rain in paper scrubs(he had been admitted two days earlier for an OD), our pt had been smoking cocaine probably laced with an alpha-2 agonist. 

Alpha-2 agonists stimulate alpha-2 receptors in the central nervous system, decreasing the activity in the sympathetic nervous system.  The sympathetic nervous system increases heart rate, blood pressure, breathing rate, and pupil size, so when its activity decreases, heart rate and blood pressure also drop.

TO REVIEW NEURAL RECEPTORS

The alpha-2 agonists commonly found in street drugs are clonidine, dexmedetomidine and xylazine.

There are many other adulterants in street drugs with a study in 2022 finding out of 5,647 samples analyzed 53 illicit  drugs were identified with THC and amphetamine being the most commonly found.

Our patient had a temp of   HR 44, bp 91/50 and  lactate  of 3.  He had a burn on the lower lip.

crack pipes often result in burns on the fingers and lips.

He was managed intially with rewarming and 1 mg of atropine.   His bp was persistently low and he was started on pressors.  Tox was consulted and they felt although cocaine which was present in his drug screen; his symptoms represented an alpha-2 receptor agonist. He was negative for xylazine.  He recovered after a brief treatment with pressors and was discharged.

FULL DISCLOSURE

Cocaine has also been associated with Type II AV block. 

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Bashour TT, Gualberto A, Ryan C    Atrioventricular block in accidental hypothermia–a case report. Angiology 1989; 40:63–66.

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Lin M.  Tricks of the trade: burned fingertips as a clinical clue. 2010 ALiEM tox  & medications, tricks of the trade

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