Some kind and good replies on the subject and thanks for the interesting 
thread...

May I add a couple of minor points:

1. As a rule (although you might wish to be tactful about it for fear of 
causing further adrenaline release) probably worth considering Cocaine in 
all "young and fit" MIs unless very excellent excuse. So you might wish to 
gently ask about Cocaine in these cases as may not volunteer information.

2. The "no brainer" is Diazepam (and Oxygen, etc). You'll need a few IV 
ampules of the juice and one oral dose of, say, 5mg. Give the patient IV 
Benzos for the central stimulatory effect, which will reduce tachy, BP (and 
pyrexia). This is something to do while thinking about the rest and is 
virtually always indicated for typical Cocaine episodes.

2.a. The oral 5mg dose is for you - you'll need it.

3. As stated, vasospasm +/- thrombus, so GTN makes sense, not only for BP. 
Nitroprusside also an option (but where the hell do you get any). And, yes, 
Phentolamine, doxazosin, hydralazine... Labetolol probably cannot be ruled 
out, especially in combination with Nitrates, although it might have less 
alpha-effect as stated in previous replies.

4. Verapamil good for tachy left after diazepam. Nifedipine useful, too, in 
view of Hypertension.

5. Now, as for BB's... THEORETICALLY-speaking, can be considered ON A 
PATIENT ALREADY ALPHA-blocked, but why bother? There are so many other 
choices and you also must consider that you could not use Nifedipine (which 
is really nice) if you use IV BB's. Also, see below (point 6.), for why 
bronchospasm may play a role, so no BB's again (and Labetolol is a tight 
option - excuse the pun). To those who, like me, always search for 
"take-home" messages, the avoidance of BB's in this case is just such a 
message. As is the Diazepam 1st step.

6. Something not much mentioned yet is the route of abuse (except mentioned 
mycotic aneurysms with IV use). Consider "Crack" smoking - inhaling very hot 
Cocaine fumes. Especially with repeated use (and not necessarily at index 
episode which might have been IV) you can get:
- Bronchiolitis with spasm (problem for BB's), thermal lung burns... Even  
proper asthma.
- Pulmonary haemorrhage and infarcts, chronic minor haemoptysis.
These latter items... Makes Thrombolysis a wee bit scary, no?

7. So, possible approach:
- Oxygen, IV accessX2, Aspirin, bla bla bla
- Get help! Now, PLEASE don't lecture me about this. I'm not an ALS manual. 
I don't mean we are too stupid in A&E to handle this. Don't have to get 
cardiologist if you hate them - just get a sensible colleague. These things 
can turn nasty and tense and you might need someone to chat with as you go, 
especially if you take the oral diazepam mentioned above.
- Diazepam!
- Diazepam!!
- Top it up with Valium!!!
- Nitrates, probably GTN infusion, as you would often anyway.
- Add Calcium-blockers if needed for BP and/or tachy.
- Morphine might help, as always, but will probably only have effect on you. 
Patients often tolerant of opioids. Still, if they still have a teeny weensy 
bit of grey jello between aural appendages, would not have taken any Heroin 
with the Coke ("Horse and Crack don' mix")
- Now step back and review results. If you are thinking Thrombolysis, think 
Cath Lab. Now suddenly you wish you HAD called in that cardiologist... But 
occasionally, I guess, Thrombolyse (again you would probably want some 
cardiologist with you, to blame for the outcome and for the missing oral 
diazepam). But watch out for fine droplet heamoptysis and wear your goggles 
and apron (and Wellies, come to think of it).

We now remove the 20/20-hindsight-omnivision-goggles...
Young woman, ranting in some Martian dialect, brought in by caring mother 
who found her outside house, ?fitting. Chest pain +++, Tachypnoea, sweaty, 
BP, say, 220/140, Pulse 160. ECG shows ST's up to here. Diagnosis MI. 
Cardiologist fast-bleeped as resuscitation begins.
Ahh... No more history. Sorry.
Consultant cardiologist knows her stuff - MI gets Aspirin ("Done, doc"), 
Morphine ("Given already, miss"), GTN infusion ("I'm getting the pump, 
gimmee a minute")...
IV Propranolol, then, while we wait...
OOPS...
Note Capitals in "OOPS"...
BP 250/160. Mercury (yes it was that long ago) in sphig seems about to spill 
out from top of tube...
Cardiologist now has similar symptoms... She looks worse than her patient 
(honest, I was there). Literally steps back, thinks, then calls for 
Nitroprusside (this is where I got the idea from). BP drops.
I don't remember what happened then. I was a clueless A&E SHO locum, but 
there was no Cath Lab. Not sure if patient Strepped or Heparinised or 
whatever they had (a few years ago), but she made it.
And she HAD had an MI...
And mommy's girl had dabbled in Cocaine (1st and, probably/hopefully, last 
time)...

The lesson being... Consider Cocaine in a young, "unexpected" MI as you may 
not be told about it and all you can think about is that post-prendial 
cardiology lecture about beta blockers in MIs...

Now where is my joint?...
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