Cocaine toxicity: Difference between revisions
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== Background == | == Background== | ||
[[File:Kokain_-_Cocaine.svg.png |thumb|Cocaine chemical structure]] | [[File:Kokain_-_Cocaine.svg.png |thumb|Cocaine chemical structure]] | ||
*Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin | *Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin | ||
== Clinical Features == | == Clinical Features== | ||
*Sympathomimetic toxidrome: | *Sympathomimetic toxidrome: | ||
**Tachycardia, diaphoresis, mydriasis, HTN, hyperthermia | **Tachycardia, diaphoresis, mydriasis, HTN, hyperthermia | ||
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**Renal failure ([[rhabdo]]) | **Renal failure ([[rhabdo]]) | ||
== Differential Diagnosis == | == Differential Diagnosis== | ||
{{Sympathomimetic types}} | {{Sympathomimetic types}} | ||
== Diagnosis == | == Diagnosis== | ||
=== Work-Up === | === Work-Up=== | ||
*Glucose | *Glucose | ||
*Chemistry | *Chemistry | ||
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**May show QRS, [[QT prolongation]] | **May show QRS, [[QT prolongation]] | ||
== Treatment == | == Treatment== | ||
#Sedation<ref>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.</ref> | #Sedation<ref>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.</ref> | ||
#*[[Diazepam]] 5-10 mg IV OR lorazepam 2mg IV q5min PRN agitation | #*[[Diazepam]] 5-10 mg IV OR lorazepam 2mg IV q5min PRN agitation | ||
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*Cardiac cath is safest option; consult (if possible) before using thrombolytics | *Cardiac cath is safest option; consult (if possible) before using thrombolytics | ||
== Disposition == | == Disposition== | ||
*Patients who do not develop complications may be discharged to home | *Patients who do not develop complications may be discharged to home | ||
*Patients demonstrating end organ dysfunction (CHF, ECG changes) should be admitted | *Patients demonstrating end organ dysfunction (CHF, ECG changes) should be admitted | ||
Revision as of 04:01, 5 July 2016
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
- Often negative in acute ingestion
- ECG
- May show QRS, QT prolongation
Treatment
- Sedation[1]
- Cooling (if needed)
- Aspirin
- 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 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 patients 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 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
- ↑ 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.
- ↑ Rosen's