We present a case of prolonged
myocardial ischemia in a young healthy male presenting for nasal polypectomy and
tonsillectomy. Induction of
anesthesia proceeded uneventfully. Immediately after
surgical incision, the patient developed a
sinus tachycardia with ST-segment depression in leads II and III, and ST elevation in leads aVR, aVL, aVF, and V. Depth of
anesthesia was increased,
esmolol was administered, which slowed the heart rate, and the procedure was terminated. However,
myocardial ischemia only gradually resolved, leaving residual T-wave flattening in lead III by day 3 postoperatively. After extensive investigation to rule out other causes of
ischemia, we considered
cardiotoxicity due to intranasally administered
cocaine with
epinephrine to be the most likely precipitant. Nasal packing with gauze soaked in a
solution containing
cocaine 3 mg/kg and
epinephrine 1 mg occurred just 40 minutes prior to induction of
anesthesia. Topical intranasal
cocaine is rapidly and reliably absorbed systemically, with peak plasma concentrations occurring within 30 to 60 minutes, corresponding to the time course of
cocaine administration and surgical stimulation in this patient. Systemic absorption of topical intranasal
cocaine has previously been reported to cause adverse cardiac sequelae, including
myocardial infarction. This report reinforces the need for caution regarding the use of topical intranasal
cocaine, particularly if used in combination with
epinephrine.