Cocaine toxicity

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)

Diagnosis

• 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

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

DDX

• See Altered Mental Status (AMS)

Treatment

1. Sedation
   1. Diazepam 5-10 mg IV OR lorazepam 2mg IV q5min PRN agitation
   2. Avoid haldol (lowers seizure threshold, contributes to dysrhythmias, hyperthermia)
2. Cooling (if needed)
3. Hypertensive emergency
   1. Benzos
   2. Phentolamine 2.5-5mg IV OR nitroprusside 0.3mcg/kg/min
   3. Beta-blockers contraindicated
4. Dysrhythmias
   1. Tachycardias usually respond to benzos
   2. Wide complex tachycardia
      1. Tx w/ bicarbonate 1-2 mEq IV bolus; titrate to pH 7.45-7.55
      2. Consider lidocaine IV if refractory to NaHCO3 (controversial)
5. STEMI
   1. 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
• Body packers should not be d/c'd until all packets removed or 3 packet-free stools
• Body stuffers who do not develop toxicity after 4hr obs can be discharged

Special Populations

1. Body Packers
   1. Multiple packets of cocaine inserted in latex bags, ingested to cross borders
   2. Each packet potentially toxic dose of cocaine
   3. Consider whole bowel irrigation
   4. Surgical removal indicated for any evidence of cocaine toxicity
2. Body Stuffers
   1. Ingestion of illicit drugs while pursued by law enforcement; usually small quantity
   2. Consider activated charcoal
   3. Consider whole bowel irrigation if develop toxicity

See Also

• Cocaine Chest Pain
• Cocaine Withdrawal

Sources

• Rosen's
• Tintinalli