Valium in Chest Pain Secondary to Stimulants

[redcrossemt]

The recent thread on caffeine got me thinking about treatment of chest pain secondary to stimulants, whether that be caffeine, cocaine, whatever.

Obviously these things can cause vasospasm, increased myocardial oxygen demand, etc., and lead to ischemia and infarction. Treatment of chest pain is typically described by the acronym "MONA", but I've heard that some services use valium for such.

There are a couple studies regarding the comparison of nitrates v. benzos I found easily. They seem to indicate that there's not a big different between them in the efficacy, but they work better in combination.

Any research on the topic? Do you have diazepam or another benzodiazepine in your protocols for cocaine-related CP? Would you use the same protocol for caffeine-related CP?

 

[Aidey]

Our protocol is for generic chest pain, without specifics for stimulant related issues. Under the Overdose/Ingestion protocol there is a line stating that stimulant ODs can be treated under the chest pain protocol if present.

I have not used benzos yet in a stimulant OD, but I have used nitro. We don't carry Morphine, just Fentanyl. I like to use the nitro first if it is appropriate, and thus far I have had good outcomes with it.

I had a good talk with a MD after a methamphetamine OD in a 25 year old woman. His opinion was O2 and nitro first and see how it goes, giving multiple doses if needed. And if that wasn't working, then low dose benzos. He said he would go to betablockers only if there was evidence of ischemia or the pts heart rate and BP were elevated for a sustained period of time after all the other treatment.

 

[thegreypilgrim]

I've found a number of studies on the phenomena of cocaine-induced chest pain, most of which seem to advocate benzodiazepines over other meds; but, I did find one which compared nitrates to benzos and found essentially no difference. Nearly all advocated against adrenergic-antagonism.

My jurisdiction has no protocol in place for anything like this, but I know that Clark County in Nevada has a protocol allowing for midazolam to be used for patients with cocaine-induced chest pain which you can find in their treatment guidelines.

 

[redcrossemt]

One study advocates the use of benzo's based on level of CNS involvement/symptoms, and the use of nitrates if there is less CNS involvement. This may be a fair treatment plan...