- The most prominent adulterant in cocaine is levamisole (found in 70% of seized cocaine in the US), which predisposes to agranulocytosis and necrotizing vasculitis.
- Black tar heroin currently makes up about 2/3 of the US market and is frequently contaminated with clostridia. Tetanus, wound botulism, and clostridial necrotizing fasciitis are risks. Make sure all heroin users are up-to-date on tetanus immunizations.
- Bath Salts primarily cause a stimulant toxidrome, and can involve fatal hyperthermia, rhabdomyolysis, and acute renal failure. Treat with benzos and aggressive cooling as needed.
- Synthetic cannabinoids (K12) can cause nausea, vomiting, syncope and seizures. Treat with benzos as needed. Of note, K12 does not show up on a standard drug screen, as it does not share key structural similarities to THC.
- Cocaine Chest Pain - patients with cocaine chest pain typically do well. Patients with positive urine cocaine tests are NOT stressed at our institution. They can be safely ruled out with serial troponins.
- Erlanger protocol doesn't just mean 2 EKGs, 2 sets of enzymes, 2 hours 'n go. They require a true reevaluation prior to discharge, EKG comparison and followup the next day - and must be low-risk.
- In the ED evaluation of the chest pain patient, classic risk factors like DM, HTN, and tobacco use are "nuisance" variables and do not affect your pretest probability. Clinician gestalt is overwhelmingly correct.
- A Coronary Calcium CT score of zero is good for approximately 1 year (and possibly longer in those aged 35-45).