Cocaine toxicity

Background

Cocaine chemical structure

• Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin

Clinical Features

• Sympathomimetic toxidrome:
  • Tachycardia, diaphoresis, mydriasis, HTN, hyperthermia
• May be associated with end organ damage:
  • Dysrhythmias
  • Aortic dissection
  • Pulmonary edema
  • MI
  • Encephalopathy
  • ICH
  • CVA
  • Intestinal ischemia
  • Renal failure (rhabdo)

Differential Diagnosis

Sympathomimetics

• Cocaine
• Amphetamines
  • Synthetic cathinones (khat)
• Ketamine
• Ecstasy (MDMA)
• Synthetic cannabinoids
• Bath salts

Diagnosis

Work-Up

• Glucose
• Chemistry
• ECG
• Troponin
• Total CK
• LFT
• Coags
• Consider CT/LP if concern for ICH
• Consider lactate/CTA if concern for bowel ischemia

Evaluation

• Generally clinical and historical diagnosis
  • See Toxidromes
• Utox is rarely helpful
  • Can be potentially positive up to 72hr post-ingestion
• ECG
  • May show QRS, QT prolongation

Treatment

• Sedation
  • Diazepam 5-10 mg IV OR lorazepam 2mg IV q5min PRN agitation
  • Avoid haldol (lowers seizure threshold, contributes to dysrhythmias, hyperthermia)
• Cooling (if needed)
• Hypertensive emergency
  • Benzos
  • Phentolamine 2.5-5mg IV (direct alpha-adrenergic antagonist, anti-hypertensive of choice) OR nitroprusside 0.3mcg/kg/min
  • Beta-blockers contraindicated
    • May cause paradoxical HTN
• Dysrhythmias
  • Tachycardias usually respond to benzos
  • Wide complex tachycardia
    • Tx w/ bicarbonate 1-2 mEq IV bolus; titrate to pH 7.45-7.55
    • Consider lidocaine IV if refractory to NaHCO3 (controversial)
• STEMI
  • Cardiac cath is safest option; consult (if possible) before using thrombolytics

Disposition

• Patients who do not develop complications may be discharged to home
• Patients demonstrating end organ dysfunction (CHF, ECG changes) should be admitted
  • Indications for admission for pts w/ cocaine intoxication and chest pain:
    • Persistent chest pain
    • ECG changes
    • Dysrhythimias
    • CHF
    • Elevated troponin
    • Requiring vasodilation
    • History of CAD or stent
    • Risk factors for CAD

Special Populations

• Body Packers
  • Multiple packets of cocaine inserted in latex bags, ingested to cross borders
  • Each packet potentially toxic dose of cocaine (death likely if bag bursts)
  • Consider whole bowel irrigation
  • Surgical removal indicated for any evidence of cocaine toxicity
  • Do not d/c until all packets removed or 3 packet-free stools
• Body Stuffers
  • Ingestion of illicit drugs while pursued by law enforcement; usually small quantity
  • Consider activated charcoal
  • Consider whole bowel irrigation if develop toxicity
  • Consider d/c if do not develop toxicity after 4hr obs

See Also

• Toxicology (Main)
• Cocaine Chest Pain
• Cocaine Withdrawal