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Crack Thumb
A 41-year-old man complaining of left-sided chest pain for 2 hours was examined in the emergency department (ED). On arrival, his blood pressure was 160/100 mm Hg; heart rate, 90 beats per minute; respiratory rate, 18 breaths per minute; oxygen saturation, 99%; and temperature, 37.2°C (99°F).
A 41-year-old man complaining of left-sided chest pain for 2 hours was examined in the emergency department (ED). On arrival, his blood pressure was 160/100 mm Hg; heart rate, 90 beats per minute; respiratory rate, 18 breaths per minute; oxygen saturation, 99%; and temperature, 37.2°C (99°F).
Drs Kari Blaho and Stephen Winbery of Memphis, Tenn, report that the patient had been a cocaine user for 10 years and had used ethanol and tobacco for 20 years. Twelve months earlier, he had undergone coronary artery bypass grafting (CABG). Presently, he was taking no medications. He had been admitted to drug rehabilitation programs on three previous occasions; the most recent was a 90-day mandatory stay from which he had been discharged within the last 10 days.
The patient was thin, alert, and oriented with a prominent CABG scar (A) on his chest, bilateral scars on his legs from vein grafts, and a blister on his right thumb (B). All other physical findings were normal. The ECG showed left ventricular hypertrophy, left atrial enlargement, and nonspecific ST-T wave changes, but no acute ischemia. The troponin-I level was less than 0.3 mg/L; other laboratory values were normal. His urine drug screen was positive for cocaine metabolites. The CABG scar suggested significant underlying coronary artery disease, which was aggravated by drug use.
The patient initially denied recent cocaine use. When asked if his right thumb injury was secondary to a lighter used for crack smoking, however, he admitted to crack cocaine use every day for the last 9 days. The patient was treated with intravenous lorazepam, after which his blood pressure decreased to 143/89 mm Hg and his heart rate dropped to 74 beats per minute. There was no recurrence of chest pain. He was discharged from the ED after 6 hours.
Drs Blaho and Winbery comment that a disposable lighter used to heat a crack pipe often causes either a callus or blister on the thumb used to ignite the lighter. This finding can be a valuable aid in identifying crack cocaine users.
