Cocaine toxicity: Difference between revisions
| Line 42: | Line 42: | ||
== Treatment == | == Treatment == | ||
*Sedation | *Sedation | ||
**Diazepam 5-10 mg IV OR lorazepam 2mg IV q5min PRN agitation | **[[Diazepam]] 5-10 mg IV OR lorazepam 2mg IV q5min PRN agitation | ||
**Avoid haldol (lowers seizure threshold, contributes to dysrhythmias, hyperthermia) | **Avoid [[haldol]] (lowers seizure threshold, contributes to dysrhythmias, hyperthermia) | ||
*Cooling (if needed) | *Cooling (if needed) | ||
*Hypertensive emergency | *Hypertensive emergency | ||
**Benzos | **[[Benzos]] | ||
**Phentolamine 2.5-5mg IV (direct alpha-adrenergic antagonist, anti-hypertensive of choice) <ref>Rosen's</ref> OR nitroprusside 0.3mcg/kg/min | **Phentolamine 2.5-5mg IV (direct alpha-adrenergic antagonist, anti-hypertensive of choice) <ref>Rosen's</ref> OR nitroprusside 0.3mcg/kg/min | ||
**Beta-blockers contraindicated | **[[Beta-blockers]] contraindicated | ||
***May cause paradoxical HTN | ***May cause paradoxical HTN | ||
===[[Dysrhythmias]]=== | |||
*Tachycardias usually respond to benzos | |||
** | *Wide complex tachycardia | ||
**Treat with 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 == | == Disposition == | ||
Revision as of 20:23, 4 June 2015
Background
- 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
- Cooling (if needed)
- Hypertensive emergency
- Benzos
- Phentolamine 2.5-5mg IV (direct alpha-adrenergic antagonist, anti-hypertensive of choice) [1] OR nitroprusside 0.3mcg/kg/min
- Beta-blockers contraindicated
- May cause paradoxical HTN
Dysrhythmias
- Tachycardias usually respond to benzos
- Wide complex tachycardia
- Treat with 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
- Indications for admission for pts w/ cocaine intoxication and chest pain:
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
References
- ↑ Rosen's