for increased stimulation by cocaine. This may worsen into coronary and periph-
eral vasoconstriction, hypertension, and possibly ischemia. Therefore, benzodi-
azepines, which decrease central sympathetic outflow, are the cornerstone in
treatment to relieve cocaine-related chest pain.
(b)Diltiazem, a CCB, can be used in patients with cocaine-related chest
pain. It is used to lower HR. (c)Aspirin should be administered to all
patients with chest pain, unless there is a contraindication. In patients with
cocaine-related chest pain who also seize, aspirin may be held until a CT scan
is performed to rule out an intracranial bleed. (d)Lorazepam, a benzodi-
azepine, is an excellent medication to use in cocaine-related chest pain as
it reduces their sympathetic drive leading to a reduction in BP and HR.
(e)Nitroglycerinshould be administered to these patients if they have
chest pain. Nitrates dilate the coronary arteries, increasing blood flow to the
myocardium.
9.The answer is a.(Tintinalli, pp 1893-1940.)The incidence of endocarditis
in the intravenous drug user (IVDU)is estimated to be 40 times that of the
general population. Unlike the general population, endocarditis in IVDUs is
typicallyright-sidedwith the majority of cases involving the tricuspid
valve.Patients with IVDU-related endocarditis usually have no evidence of
prior valve damage. Patients may present with fever, cardiac murmur, cough,
pleuritic chest pain, and hemoptysis. Right-sided murmurs, which vary with
respiration, are typically pathologic and more specific for the diagnosis. In
patients with right-sided endocarditis and septic pulmonary emboli, pul-
monary complaints, infiltrates on chest radiographs, and moderate hypoxia
have been described in greater than 33% of patients; these symptoms and
signs may mislead the physician to identify the lung as the primary source of
infection.Blood cultureswill be positive in more than 98% of IVDU-related
endocarditis patients if 3 to 5 setsare obtained. Diagnosis generally requires
microbial isolation from a blood culture or to demonstrate typical lesions on
echocardiography. TTEis the most sensitive imaging modality for demon-
strating vegetations and tricuspid valve involvement in IVDU-related endo-
carditis. Initial antibiotic treatment should be directed against Saureusand
Streptococcusspecies.
(b)Mononucleosis presents with fever, sore throat, and lymphadenopa-
thy. Patients may also have an enlarged spleen, which is more prone to
trauma. However, mononucleosis does not cause a heart murmur or patchy
infiltrates on chest radiograph. (c)Pericarditis can present withfever and
28 Emergency Medicine