Cocaine toxicity

Revision as of 02:39, 23 July 2016 by Neil.m.young (talk | contribs) (Text replacement - "==Diagnosis==" to "==Evaluation==")

Background

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

Clinical Features

Differential Diagnosis

Sympathomimetics

Evaluation

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
  • Utox is rarely helpful
    • Can be potentially positive up to 72hr post-ingestion
    • Often negative in acute ingestion
  • ECG

Management

  1. Sedation[1]
    • Diazepam 5-10mg IV OR lorazepam 2mg IV q5min PRN agitation
    • Avoid haldol (lowers seizure threshold, contributes to dysrhythmias, hyperthermia)
  2. Cooling (if needed)
  3. Aspirin
  4. Hypertensive emergency
    • Benzos
    • Phentolamine 2.5-5mg IV (direct alpha-adrenergic antagonist, anti-hypertensive of choice) [2] OR nitroprusside 0.3mcg/kg/min
    • Beta-blockers contraindicated
      • May cause paradoxical HTN

Dysrhythmias

  • Tachycardias usually respond to benzos
  • Wide complex tachycardia (deviation from ACLS)
    • 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 patients with 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 discharge 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 discharge if do not develop toxicity after 4hr obs

See Also

References

  1. McCord, J., Jneid, H., Hollander, J. E., de Lemos, J. A., Cercek, B., Hsue, P., Gibler, W. B., Ohman, E. M., Drew, B., Philippides, G. and Newby, L. K. (2008) ‘Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement From the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology’, Circulation, 117(14), pp. 1897–1907. doi: 10.1161/circulationaha.107.188950.
  2. Rosen's