256 Emergency Medicine
toxicity are contradictory. Therefore, their role in patients with cocaine intoxi-
cation remains unclear.
229.The answer is d.(Goldfrank et al, pp 41059-41069.)Opioid withdrawal
initially presents with drug craving, yawning, rhinorrhea, and piloerection and
progresses to nausea, vomiting, diarrhea, hyperactive bowels, diaphoresis,
myalgias, arthralgias, anxiety, fear, and mild tachycardia. Methadone with-
drawalstarts approximately 24 hours after the last dose and persists for 3 to
7 days. Heroin withdrawal begins about 6 hours after the last dose and usually
fully manifests at 24 hours. Opioid withdrawal is not a life-threatening condi-
tion as long as adequate hydration and nutritional support is maintained.
(a)Ethanol withdrawal is a life-threatening condition that develops 6 to
24 hours after the reduction of ethanol intake. It is characterized by auto-
nomic hyperactivity, including nausea, anorexia, coarse tremor, tachycardia,
hypertension, hyperreflexia, sleep disturbances, hallucinations, and seizure.
(b)When cocaine use is stopped or when a binge ends, a crash follows almost
immediately. This is accompanied by a strong craving for more cocaine,
fatigue, lack of pleasure, anxiety, irritability, sleepiness, and sometimes agita-
tion or extreme suspicion. (c)Nicotine withdrawal manifests largely as ciga-
rette craving and subjective dysphoric symptoms. There are some symptoms
of irritability and restlessness. (e)Discontinuation of clonidine leads to
headache, flushing, sweating, hallucinations, anxiety, and reflex tachycardia.
230.The answer is d.(Goldfrank et al, pp 11034-11041. Rosen, pp 2145-
2148.)PCP intoxicationis characterized by a wide spectrum of findings.
Behavior may be bizarre, agitated, confused, or violent. The hallmark of PCP
toxicity is the recurring delusion of superhuman strength and invulnera-
bilityresulting from both the anesthetic and dissociative properties of the
drug. Patients have broken police handcuffs, fracturing bones in doing so.
The major cause of death or injury from PCP is behavioral toxicity leading to
suicide and provoked homicide. Typical neurologic signs include nystagmus
(horizontal, vertical, or rotary), ataxia, and altered gait. Pupils are usually
midsized and reactive, but can be mydriatic or miotic. Bizarre posturing, gri-
macing, and writhing may be seen. Management is conservative. To prevent
self-injury, the patient must be safely restrained. Antipsychotics or benzodi-
azepines are frequently administered for chemical sedation. PCP intoxication
usually ranges from 8 to 16 hours, but can last longer in chronic users.
(a and c)Cocaine and amphetamines are sympathomimetics that can be
confused with PCP intoxication. However, the hallmark to PCP intoxication
that is not usually observed in sympathomimetic intoxication is the recurring