A 17‐year‐old girl is brought to the emergency department by paramedics

A 17‐year‐old girl is brought to the emergency department by paramedics. She had been at a party that evening that was described as being “wild” by her friends who called the ambulance. In the early morning hours, she was found unconscious and barely breathing. Her friends also told paramedics that she was known to get high with her boyfriend on more than one occasion. On physical examination, her pupils are dilated and there is hemorrhagic, frothy fluid in her mouth. Her pulse is 100/min, respirations are 6/min, and her blood pressure is 70/35 mmHg. What is the most likely cause of this patient’s condition?

  • A. Amphetamines
  • B. Cocaine
  • C. Parathion
  • D. Phencyclidine

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The correct answer is B. This patient has the typical presentation of cocaine overdose.
Cocaine gives a feeling of euphoria and may lead to central nervous system stimulation
with restlessness, excitement, agitation, increased motor activity, mydriasis, increased
respiratory rate, and hypertension. Later, the patient may experience hypotension with
seizure, coma, and respiratory depression. Often, the patients will complain of chest pain secondary to myocardial injury that ranges from angina pectoris to myocardial infarction.
There may be nausea, insomnia, and emaciation in the chronic user. Complications
include cerebrovascular accidents secondary to hypertension, rhabdomyolysis,
pulmonary edema with alveolar hemorrhage (hence the hemorrhagic, frothy fluid in this
patient), pneumomediastinum, or pneumothorax. Cardiomyopathy in chronic users may
lead to depressed cardiac function and death.
Amphetamines (choice A) are stimulants and intoxication manifests with hyperactivity,
irritability, delirium, hallucinations, psychosis, mydriasis, hyperpyrexia, hypertension,
arrhythmias, vomiting, and diarrhea. Less commonly, acute renal failure, seizures,
central nervous system hemorrhage, coma, myocardial infarction, and circulatory
collapse may occur.
Parathion (choice C) is an organophosphate insecticide responsible for a number of
suicidal and agricultural poisonings. Nonketotic hyperglycemia and glycosuria are
common in these patients. Clinical manifestations are the consequence of anticholinergic
effects on the central nervous system and include myosis, increased lacrimation, blurred vision, bradycardia, hypotension, urinary incontinence, fasciculations, cramps, delirium, coma, seizures, and respiratory depression.
Phencyclidine (choice D) is a dissociative anesthetic and is available illicitly as LSD,
mescaline, psilocybin, and tetrahydrocannabinol. Coma, hypertension, hyperpyrexia,
hypertonicity, and bronchospasm characterize moderate intoxication.