What is the appropriate evaluation and management for a 16-year-old patient presenting to the pediatric emergency room with a history of cocaine use, alcohol consumption, and back pain?

Evaluation and Management of a 16-Year-Old with Substance Use and Back Pain in the Pediatric ER

The comprehensive evaluation of a 16-year-old presenting with back pain after cocaine and alcohol use should include cardiac assessment, toxicology screening, and pain evaluation, with particular attention to potential cardiovascular complications of cocaine use. 1

History Questions to Ask

Substance Use History

• Timing of cocaine use - when exactly did the patient use cocaine? (Cocaine effects can last 24-48 hours) 1
• Route of administration (intranasal, smoking, intravenous) 1
• Amount of cocaine consumed 1
• Frequency of cocaine use (first-time or chronic user) 1
• Alcohol consumption details (amount, timing, type) 1
• Cannabis use details (amount, timing, method) 1
• Use of other substances or medications 1

Pain Assessment

• Location - confirm right mid-back pain and any radiation 1
• Onset - when did the pain begin in relation to substance use? 1
• Character - quality of pain (sharp, dull, pressure-like) 1
• Severity on scale of 1-10 1
• Aggravating/alleviating factors - does movement or position change affect pain? 1
• Associated symptoms (nausea, vomiting, diaphoresis, dyspnea) 1

Cardiovascular Symptoms

• Presence of chest pain (cocaine-associated chest pain is often pressure-like) 1
• Dyspnea (occurs in up to 60% of patients with cocaine-related cardiac issues) 1
• Palpitations, dizziness, or syncope 1
• Diaphoresis (occurs in about 40% of patients with cocaine-related cardiac issues) 1

Past Medical History

• Previous substance use or addiction 1
• Previous cardiac issues 2
• History of hypertension, hyperlipidemia, diabetes 2
• Family history of premature coronary artery disease 2
• Previous trauma or back problems 1

Physical Examination Focus

Vital Signs

• Continuous monitoring of elevated heart rate (currently 145 bpm) 1
• Serial blood pressure measurements (currently 131/78 mmHg) 1
• Temperature monitoring for hyperthermia 1
• Respiratory rate and oxygen saturation 1

Cardiovascular Examination

• Heart sounds for murmurs, gallops, or rubs 1
• Peripheral pulses and perfusion 1
• Signs of heart failure 1

Back Examination

• Tenderness to palpation 1
• Range of motion 1
• Muscle spasm or guarding 1
• Neurological examination including reflexes and sensation 1

Neurological Examination

• Detailed neurological exam beyond PERLA 1
• Signs of agitation, anxiety, or psychosis 3
• Coordination and balance 3

Diagnostic Workup

Laboratory Tests

• Urine toxicology screen to confirm substances used 1
• Cardiac biomarkers (troponin) to assess for myocardial injury 1
• Complete blood count 1
• Comprehensive metabolic panel 1
• Creatine kinase to assess for rhabdomyolysis (common with cocaine use) 1
• Coagulation studies 1

Imaging

• 12-lead ECG (essential for all patients with cocaine use and pain) 1
• Chest X-ray 1
• Consider spine imaging if neurological deficits are present 1
• Consider echocardiogram if cardiac symptoms or ECG abnormalities are present 1

Additional Testing

• Consider myocardial perfusion imaging if cardiac symptoms persist 1
• Consider observation for 9-12 hours with serial troponin measurements at 3,6, and 9 hours 1

Management Plan

Immediate Management

• Continuous cardiac monitoring 1
• IV access 1
• Oxygen if needed 1
• For cocaine-related cardiac symptoms, administer sublingual nitroglycerin or calcium channel blockers (e.g., diltiazem 20 mg IV) rather than beta-blockers 1
• Benzodiazepines for agitation or anxiety 1

Pain Management

• Avoid NSAIDs if cocaine-induced platelet dysfunction is suspected 1
• Consider acetaminophen for pain 1
• Avoid opioids if possible due to substance use history 1

Cardiovascular Management

• If ECG shows ST-segment changes and cardiac biomarkers are normal, observe in hospital for 24 hours 1
• Avoid beta-blockers in cocaine-induced cardiovascular complications as they may worsen coronary vasoconstriction 1
• For cocaine-induced chest pain, calcium channel blockers are preferred 1

Disposition Planning

• If cardiac evaluation is negative and back pain is musculoskeletal, consider discharge after observation period 1
• If signs of serious pathology, admit for further management 1
• Substance use counseling before discharge 1
• Follow-up arrangements with primary care and substance abuse treatment 1

Special Considerations

Cardiovascular Complications

• Cocaine increases risk of myocardial ischemia, infarction, and arrhythmias 4
• Tachycardia (current HR 145) may be due to cocaine effect or pain 1
• Cocaine users can develop ischemic chest pain indistinguishable from ACS 1
• Back pain could potentially represent aortic dissection, which is associated with cocaine use 1

Substance Use Complications

• Combined use of cocaine and alcohol produces cocaethylene, which has longer-lasting cardiotoxic effects 5
• Cocaine can cause rhabdomyolysis, which may present with back pain 1
• Cannabis use may mask or alter pain perception 1

Age-Specific Considerations

• Adolescents may underreport substance use 1
• Parental/guardian involvement in care decisions 1
• Mandatory reporting requirements for substance use in minors 1