Images in Emergency Medicine

Article Outline

• Diagnosis
  • Fingertip burns from a crack pipe
• Copyright

Crack cocaine users often sustain fingertip burns from holding heated crack pipes. Such burns may provide a visual clue to emergency physicians for possible underlying cocaine intoxication.

A 35-year-old woman was brought to the emergency department (ED) for agitation. Her physical examination was limited by her bouts of yelling and moaning. After the patient was chemically sedated, her vital signs normalized, with her initial tachycardia of 120 beats/min improving to 95 beats/min. A more thorough examination was unremarkable, including reactive pupils at 5 mm, no smell of alcohol on her breath, and no appreciable toxidrome by examination. The tip of her left ring finger, however, was covered with a Band-Aid. Removing this Band-Aid revealed erythema over the volar aspect of the distal phalanx, consistent with a thermal burn (Figure 1).

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• Figure 1. 

  Fingertip thermal burn.

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Diagnosis 

Fingertip burns from a crack pipe 

Burned fingertips are a telltale injury from smoking crack cocaine because crack is often smoked in noninsulated glass or metal pipes. Handling these hot pipes, nicknamed “stems” or “blasters,” often leads to thermal injuries of fingertips and even lips. The suspicion for cocaine in this patient was confirmed by finding a glass crack pipe (Figure 2) in her belongings and later a urine toxicology report positive for cocaine.

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• Figure 2. 

  Glass crack cocaine pipe. Used with permission of Chinyere Mbagwu, BA, and Michelle Lin, MD, University of California San Francisco, San Francisco General Hospital, Emergency Services, San Francisco, CA.

Cocaine intoxication can change the evaluation and treatment of ED patients, such as those presenting with altered mental status, chest pain, or fevers. A careful examination of patients' fingertips for burns may provide the only initial toxicologic clue for cocaine use.