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Drug Abuse and Drug Abuse and WoundsWounds
Ronald A. Kline, M.D., Ronald A. Kline, M.D., F.A.C.S., F.A.H.A.-S.C.F.A.C.S., F.A.H.A.-S.C.
Arizona Endovascular CenterArizona Endovascular Center
Chief, Division of Vascular & Chief, Division of Vascular & Endovascular Surgery, Carondelet St. Endovascular Surgery, Carondelet St.
Joseph HospitalJoseph Hospital
Medical Director Wound Care, Medical Director Wound Care, Carondelet St. Joseph Hospital and Carondelet St. Joseph Hospital and
Kindred Hospital TucsonKindred Hospital Tucson
A Legal DrugA Legal Drug
Antique SyringeAntique Syringe
Antique SyringeAntique Syringe 1670 crude forms 1670 crude forms
of IV injectionsof IV injections 1853 Charles 1853 Charles
Pravaz & Pravaz & Alexander Wood Alexander Wood simultaneously simultaneously develop modern develop modern style syringestyle syringe
United KingdomUnited Kingdom
1860 all drugs legal and used across 1860 all drugs legal and used across societysociety
Prime Minister William Gladstone & Prime Minister William Gladstone & Florence Nightingale use opiumFlorence Nightingale use opium
Queen Victoria used cannabisQueen Victoria used cannabis Sherlock Holmes (Sir Arthur Conan Sherlock Holmes (Sir Arthur Conan
Doyle) injected opium derivative Doyle) injected opium derivative during case hiatus for relaxationduring case hiatus for relaxation
PrevalencePrevalence
50% of DRH trauma patients test 50% of DRH trauma patients test positive for cocaine, heroin or bothpositive for cocaine, heroin or both
1998 estimate by National Institute of 1998 estimate by National Institute of Drub Abuse 21 million of USA have Drub Abuse 21 million of USA have tried cocaine, 3 million within last tried cocaine, 3 million within last monthmonth
Cocaine related violent deaths in Salt Cocaine related violent deaths in Salt Lake City & Tucson are risingLake City & Tucson are rising
1.8 million patients / year admitted 1.8 million patients / year admitted for treatment in the USAfor treatment in the USA
Anatomy of a Crack PipeAnatomy of a Crack Pipe
Changeable screen
Crack rocks burned here
Mouthpiece
Coolant chamber
““The Blind Eye”The Blind Eye”
Drug Abuse Warning Network Drug Abuse Warning Network (DAWN)(DAWN) Section of US Health & Human Services Section of US Health & Human Services
are under reporting to Congressare under reporting to Congress 1992 reported 5% incidence of cocaine use 1992 reported 5% incidence of cocaine use
in patients treated at Hospital of the in patients treated at Hospital of the University of PennsylvaniaUniversity of Pennsylvania
Hospital prospective internal review showed Hospital prospective internal review showed 20% of blunt trauma and 57 % penetrating 20% of blunt trauma and 57 % penetrating trauma victims tested positive for cocainetrauma victims tested positive for cocaine
MarijuanaMarijuana
Research indicates more Research indicates more carcinogens than in tobaccocarcinogens than in tobacco
Bladwin at UCLA: alveolar Bladwin at UCLA: alveolar macrophages have reduced macrophages have reduced bactericidal activity to bactericidal activity to Staph. Staph. AureousAureous
Users with depressed cytotoxic and Users with depressed cytotoxic and immunoprotective levels of immunoprotective levels of interleukin-6interleukin-6
CocaineCocaine
Alkaloid extract of Alkaloid extract of Erythroxylon Erythroxylon coca, coca, powder formpowder form
Purified by dissolving in acetone or Purified by dissolving in acetone or alcohol and smoked as “free base”alcohol and smoked as “free base”
Alkaloid dissolved in HCl acid to Alkaloid dissolved in HCl acid to form water soluble saltform water soluble salt
““Crack” is the neutral form made Crack” is the neutral form made without solvent extraction by adding without solvent extraction by adding an alkali to cocaine hydrochloridean alkali to cocaine hydrochloride
CocaineCocaine
Crack is the most common cause of MI Crack is the most common cause of MI and / or strokes in young Americansand / or strokes in young Americans
It affects arteries of all sizesIt affects arteries of all sizes Transpulmonic absorption is increased Transpulmonic absorption is increased
by a two person Valsalva’s maneuverby a two person Valsalva’s maneuver Acute mediastinal air dissectionAcute mediastinal air dissection Care is supportiveCare is supportive Transcoronary or carotid air dissectionsTranscoronary or carotid air dissections
Cocaine EffectsCocaine Effects
Dose dependentDose dependent Local anesthesiaLocal anesthesia Local vasoconstrictionLocal vasoconstriction Sympathomimetic action by blocking Sympathomimetic action by blocking
re-uptake of norepinephrine and re-uptake of norepinephrine and dopaminedopamine
Cocaine EffectsCocaine Effects
Pathophysiologic effectsPathophysiologic effects ΔΔp / p / ΔΔt = dissectionst = dissections Spasm in medium & small sized arteriesSpasm in medium & small sized arteries
GI bleedsGI bleeds Induces hypercoagulabilityInduces hypercoagulability
Platelet aggregationPlatelet aggregation Decreases protein C and anti-thrombin III Decreases protein C and anti-thrombin III
levelslevels Inhibits thrombolysisInhibits thrombolysis
Crack Induced Aortic Crack Induced Aortic DissectionDissection
14 year old after 14 year old after acute crack usageacute crack usage
Intra-aortic ThrombosisIntra-aortic Thrombosis
PCP or “Angel Dust”PCP or “Angel Dust”
Hog, squeeze, wack, space base (mixed Hog, squeeze, wack, space base (mixed with crack)with crack)
1-(1-phencyclohexyl) piperidine1-(1-phencyclohexyl) piperidine Original form mixed with heroine, now Original form mixed with heroine, now
cocainecocaine Mixing potentiates each effects and Mixing potentiates each effects and
reduces the LDreduces the LD5050
3 – 8 mg mild intoxication3 – 8 mg mild intoxication 8 – 12 mg HTN, fever, “ zombie walk”8 – 12 mg HTN, fever, “ zombie walk”
PCP or “Angel Dust”PCP or “Angel Dust”
> 12 mg profound hypotension, > 12 mg profound hypotension, coma, convulsions, muscular coma, convulsions, muscular rigidity, deathrigidity, death Effects last for daysEffects last for days Rabdomyolysis necessitates Rabdomyolysis necessitates
fasciotomiesfasciotomies Treatment is supportive Treatment is supportive
AmphetaminesAmphetamines
Methamphetamine & “Ecstasy”Methamphetamine & “Ecstasy” 3,4-methylenedioxymethamphetamine3,4-methylenedioxymethamphetamine
Inotropic and chronotropic effects Inotropic and chronotropic effects like cocainelike cocaine Strokes and aortic dissectionsStrokes and aortic dissections Chronic usage: depressionChronic usage: depression
““Meth” labsMeth” labs House buyers bewareHouse buyers beware
Other AgentsOther Agents
Anything that can be dissolved or Anything that can be dissolved or liquified has been injectedliquified has been injected Acetominaphine, codeine, TalwinAcetominaphine, codeine, Talwin®®
Incomplete dissolution or precipitation Incomplete dissolution or precipitation problematicproblematic
Inadvertent intra-arterial injectionInadvertent intra-arterial injection Common in hand and forearmCommon in hand and forearm CarotidCarotid Treatment is heparin and await for Treatment is heparin and await for
demarcationdemarcation
““Trashed” HandsTrashed” Hands
Arm FasciotomyArm Fasciotomy