Cocaine toxicity

Background

• Naturally occurring alkaloid derived from cocoa plant
• Mechanism of action is blockade of reuptake of neurotransmitters at the neuromuscular junction
• Also works as class IA antidysrhythmic and local anesthetic
• Routes of administration:
  • Inhalation
  • intranasal
  • intravenous
  • Oral
  • IM/SQ/Skin popping

Clinical Features

• Sympathomimetic toxidrome - tachycardic, diaporetic, mydriasis, hypertension, hyperthermia
  • See Toxidromes
• May be associated with end organ damage
  • Cardiac dysrhythmias
  • Aortic dissection
  • Pulmonary edema
  • MI
  • ICH
  • Stroke
  • Anterior spinal artery infarction
  • Altered mental status

Diagnosis

• Generally clinical and historical diagnosis
  • See Toxidromes
• Utox is rarely helpful
  • Can be potentially positive up to 72 hrs after ingestion

Work-Up

• Accucheck
• ECG
• Cardiac Markers
• Total CK
• complete metabolic panel
• LFTs
• Coags
• Fibrin split products
• Consider CT/LP if concern for ICH
• Consider lactate/CTA if concerned for bowel ischemia

DDX

• See Altered Mental Status (AMS)

Treatment

• ABC
• Benzodiazepines
  • Diazepam 10 mg IV q5min PRN agitation
• Note: Droperidol, Haldol, other phenothiazines should be avoided for concern for anticholinergic effects exacerbating hyperthermia
• 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

• 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
• Body packers should not be discharged until all packets have been removed or 3 packet free stools
• Body stuffers who do not develop toxicity after 4 hours of observation can be discharged

Sources

Rosens