Cocaine toxicity: Difference between revisions
 
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==Background==
[[File:Kokain_-_Cocaine.svg.png |thumb|Cocaine chemical structure]]
[[File:CocaineHydrochloridePowder cropped.jpg|thumb|A pile of cocaine hydrochloride]]
[[File:Rocks of crack cocaine.jpg|thumb|"Rocks" of crack cocaine]]
*Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin
*A [[Sympathomimetic toxicity|sympathomimetic]] stimulant derived from an alkaloid paste made from the leaves of the coca plant
*Both a legitimate medical drug and a drug of abuse


== Background ==
===Forms of Abuse===
*Naturally occurring alkaloid derived from cocoa plant
*Cocaine can be smoked, snorted, injected or ingested
*Mechanism of action is blockade of reuptake of neurotransmitters at the neuromuscular junction
*Smoked form is often in a free-base or crack form
*Also works as class IA antidysrhythmic and local anesthetic
*Routes of administration:
**Inhalation
**intranasal
**intravenous
**Oral
**IM/SQ/Skin popping


== Clinical Features ==
==Clinical Features==
*Sympathomimetic toxidrome - tachycardic, diaporetic, mydriasis, hypertension, hyperthermia
[[File:Side effects of chronic use of Cocaine.png|thumb|Side effects of chronic cocaine use]]
**See [[Toxidromes]]
*Sympathomimetic toxidrome:
*May be associated with end organ damage
**Tachycardia, diaphoresis, mydriasis, hypertension, hyperthermia, agitation
**Cardiac dysrhythmias
*[[Cocaine-associated chest pain]]
**Aortic dissection
*"[[Crack lung]]"
**Pulmonary edema
*"Crack dancing" (choreoathetoid movement disorder)
**MI
*May be associated with end organ damage:
**ICH
**[[Dysrhythmias]]
**Stroke
**[[Aortic dissection]]
**Anterior spinal artery infarction
**[[Pulmonary edema]]
**Altered mental status
**[[MI]]
**[[Encephalopathy]]
**[[ICH]]
**[[CVA]]
**Intestinal ischemia
**Renal failure ([[rhabdomyolysis]])


== Diagnosis ==
==Differential Diagnosis==
*Generally clinical and historical diagnosis
{{Sympathomimetic types}}
**See [[Toxidromes]]
{{Drugs of abuse types}}
*Utox is rarely helpful
**Can be potentially positive up to 72 hrs after ingestion


== Work-Up ==
==Evaluation==
*Accucheck
===Work-Up===
*ECG
*Glucose
*Cardiac Markers
*Chemistry
*[[ECG]]
*[[Troponin]]
*Total CK
*Total CK
*complete metabolic panel
*LFT
*LFTs
*Coags
*Coags
*Fibrin split products
*Consider CT/LP if concern for ICH
*Consider CT/LP if concern for ICH
*Consider lactate/CTA if concerned for bowel ischemia
*Consider lactate/CTA if concern for bowel ischemia


== DDX ==
===Evaluation===
*See [[Altered Mental Status (AMS)]]
*Generally clinical and historical diagnosis
**See [[Toxidromes]]
*[[Urine toxicology screen]] is rarely helpful
**Can be potentially positive up to 72hr post-ingestion
**Often negative in acute ingestion
*[[ECG]]
**May show QRS, [[QT prolongation]]


== Treatment ==
===Detection===
*ABC
*Unreliable in very acute intoxication<ref>McCord J, et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117: 1897-1907.</ref>
*Benzodiazepines
*Qualitative urine detection of cocaine metabolite benzoylecgonine at cut-off of 300 ng/ml
**Diazepam 10 mg IV q5min PRN agitation
**On average, shows up in urine 24-48 hrs after use
*Note: Droperidol, Haldol, other phenothiazines should be avoided for concern for anticholinergic effects exacerbating hyperthermia
**Up to 22 days in chronic users
*Rapid cooling if hyperthermic, goal to reduce temperature to < 102F in 20 min
**IVFs
**Cooling blankets
**Ice water
**wet sheets
**large fans
*Hypertensive emergencies
**Phentolamine 1-5 mg IV to decrease bp 25% in first hour, with ultimate goal of achieving normal blood pressure
**May consider Nitroprusside or Nitrate gtt
**Beta blockers are contraindicated
*Dysrhythmias
**Tachycardias usual respond to benzodiazepines
**Wide complex tachycardia can be treated with bicarbonate 1-2 mEq IV bolus, consider lidocaine IV if refractory
*See [[Cocaine Chest Pain]]
*Body Packers
**Multiple packets of cocaine inserted in latex bags and ingested with intention of transport of illicit drugs across international borders
**Each packet potentially toxic dose of cocaine
**Close monitoring warranted
**Consider activated charcoal
**Whole bowel irrigation with polyethylene glycol
**Surgical removal if any evidence of cocaine toxicity
**Endoscopic removal is contraindicated for fear of rupturing container
*Body Stuffers
**Ingestion of illicit drugs while pursued by law enforcement, unplanned event; usually small quantities
**Consider activated charcoal
**Consider whole bowel irrigation if development of toxicity


== Disposition ==
==Management==
#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]] 5-10mg IV OR lorazepam 2mg IV q5min PRN agitation
#*Avoid [[haldol]] if patient has abnormal vital signs (lowers seizure threshold, contributes to dysrhythmias, hyperthermia)
#Cooling (if needed)
#Aspirin
#Hypertensive emergency
#*[[Benzos]]
#*Phentolamine 2.5-5mg IV (direct α-adrenergic antagonist, anti-hypertensive of choice) <ref>Rosen's</ref> OR nitroprusside 0.3mcg/kg/min
#*[[Beta-blockers]] contraindicated
#**May cause paradoxical hypertension
#IV crystalloid replacement (most patients have salt and water depletion)
 
===[[Dysrhythmias]]===
*Tachycardias usually respond to [[benzodiazepines]]
*Wide complex tachycardia (deviation from ACLS)
**Treat with bicarbonate 1-2 mEq/kg IV bolus; titrate to pH 7.45-7.55
***Cocaine has sodium-channel blockade effect (similar to [[TCA]] toxicity)
**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 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 (e.g. CHF) should be admitted
**Indications for admission for patients with cocaine intoxication and chest pain
 
***Persistent chest pain
==Special Populations==
***ECG changes
*[[Cocaine-associated chest pain]]
***Dysrhythimias
*[[Levamisole toxicity]] (rash, neutropenia, vasculitis)
***CHF
**Up to 70% of US cocaine contaminated
***Elevated troponin
*[[Acute pulmonary toxicity from crack cocaine]] (Crack lung)
***Requiring vasodilation
*[[Body packing]]
***History of CAD or stent
**Multiple packets of cocaine inserted in latex bags, ingested to cross borders
***Risk factors for CAD
**Each packet potentially toxic dose of cocaine (death likely if bag bursts)
*Body packers should not be discharged until all packets have been removed or 3 packet free stools
**Consider whole bowel irrigation, via NGT at 2L per hour
*Body stuffers who do not develop toxicity after 4 hours of observation can be discharged
**Endoscopy contraindicated (high % leakage/rupture of packets)
**Surgical removal indicated for any evidence of cocaine toxicity
**Do not discharge until all packets removed or 3 packet-free stools
**Do not use oil based laxatives, they reduce the tensile strength of packets
*[[Body stuffing]]
**Ingestion of illicit drugs while pursued by law enforcement; usually small quantity
**Consider [[activated charcoal]], 1g/kg (up to 50g) PO q4hours for several doses
**Consider whole bowel irrigation if develop toxicity
**Consider discharge if do not develop toxicity after 4hr obs
 
==Complications==
===Acute===
*[[Cocaine-associated chest pain]]
*Sympathomimetic qualities
**Tachycardia
**Fever
**Agitation
**Diaphoresis
*Pulmonary Complications:
**"[[Crack lung]]"<ref>Forrester, J. M., Steele, A. W., Waldron, J. A. and Parsons, P. E. (1990) ‘Crack Lung: An Acute Pulmonary Syndrome with a Spectrum of Clinical and Histopathologic Findings’, American Review of Respiratory Disease, 142(2), pp. 462–467. doi: 10.1164/ajrccm/142.2.462.</ref>
**Diffuse alveolar hemorrhage<ref>Ettinger, N. A. and Albin, R. J. (1989) ‘A review of the respiratory effects of smoking cocaine’, The American Journal of Medicine, 87(6), pp. 664–668. doi: 10.1016/s0002-9343(89)80401-2.</ref>
**[[ARDS]]
**Acute eosinophilic pneumonia
**[[Pneumothorax]]
**[[Pneumomediastinum]]
**Thermal epiglottitis - hot cocaine
*Other Complications
**[[Rhabdomyolysis]]
**[[glaucoma|Angle closure glaucoma]]
 
===Chronic===
*Atherosclerosis
*Cardiomyopathy
*Nasal Septum damage
*Up to 70% of US cocaine tainted with [[levamisole]], potentially leading to [[neutropenia]], [[vasculitis]]
 
==See Also==
*[[Toxicology (Main)]]
*[[Cocaine-associated chest pain]]
*[[Acute pulmonary toxicity from crack cocaine]]
*[[Cocaine Withdrawal]]
*[[Cocaine]]
*[[Levamisole toxicity]]
 
==References==
<references/>


== Sources ==
[[Category:Toxicology]]
Rosens

Latest revision as of 01:47, 11 February 2021

Background

Cocaine chemical structure
A pile of cocaine hydrochloride
"Rocks" of crack cocaine
  • Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin
  • A sympathomimetic stimulant derived from an alkaloid paste made from the leaves of the coca plant
  • Both a legitimate medical drug and a drug of abuse

Forms of Abuse

  • Cocaine can be smoked, snorted, injected or ingested
  • Smoked form is often in a free-base or crack form

Clinical Features

Side effects of chronic cocaine use

Differential Diagnosis

Sympathomimetics

Drugs of abuse

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

Detection

  • Unreliable in very acute intoxication[1]
  • Qualitative urine detection of cocaine metabolite benzoylecgonine at cut-off of 300 ng/ml
    • On average, shows up in urine 24-48 hrs after use
    • Up to 22 days in chronic users

Management

  1. Sedation[2]
    • Diazepam 5-10mg IV OR lorazepam 2mg IV q5min PRN agitation
    • Avoid haldol if patient has abnormal vital signs (lowers seizure threshold, contributes to dysrhythmias, hyperthermia)
  2. Cooling (if needed)
  3. Aspirin
  4. Hypertensive emergency
    • Benzos
    • Phentolamine 2.5-5mg IV (direct α-adrenergic antagonist, anti-hypertensive of choice) [3] OR nitroprusside 0.3mcg/kg/min
    • Beta-blockers contraindicated
      • May cause paradoxical hypertension
  5. IV crystalloid replacement (most patients have salt and water depletion)

Dysrhythmias

  • Tachycardias usually respond to benzodiazepines
  • Wide complex tachycardia (deviation from ACLS)
    • Treat with bicarbonate 1-2 mEq/kg IV bolus; titrate to pH 7.45-7.55
      • Cocaine has sodium-channel blockade effect (similar to TCA toxicity)
    • 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 (e.g. CHF) should be admitted

Special Populations

  • Cocaine-associated chest pain
  • Levamisole toxicity (rash, neutropenia, vasculitis)
    • Up to 70% of US cocaine contaminated
  • Acute pulmonary toxicity from crack cocaine (Crack lung)
  • Body packing
    • 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, via NGT at 2L per hour
    • Endoscopy contraindicated (high % leakage/rupture of packets)
    • Surgical removal indicated for any evidence of cocaine toxicity
    • Do not discharge until all packets removed or 3 packet-free stools
    • Do not use oil based laxatives, they reduce the tensile strength of packets
  • Body stuffing
    • Ingestion of illicit drugs while pursued by law enforcement; usually small quantity
    • Consider activated charcoal, 1g/kg (up to 50g) PO q4hours for several doses
    • Consider whole bowel irrigation if develop toxicity
    • Consider discharge if do not develop toxicity after 4hr obs

Complications

Acute

Chronic

See Also

References

  1. ↑ McCord J, et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117: 1897-1907.
  2. ↑ 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.
  3. ↑ Rosen's
  4. ↑ Forrester, J. M., Steele, A. W., Waldron, J. A. and Parsons, P. E. (1990) ‘Crack Lung: An Acute Pulmonary Syndrome with a Spectrum of Clinical and Histopathologic Findings’, American Review of Respiratory Disease, 142(2), pp. 462–467. doi: 10.1164/ajrccm/142.2.462.
  5. ↑ Ettinger, N. A. and Albin, R. J. (1989) ‘A review of the respiratory effects of smoking cocaine’, The American Journal of Medicine, 87(6), pp. 664–668. doi: 10.1016/s0002-9343(89)80401-2.
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