Cocaine toxicity: Rapid overview of emergency management

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links).

General

Cocaine is a stimulant (sympathomimetic) that increases energy and produces euphoria

Cocaine produces toxicity in virtually every organ system, principally via hemodynamic effects

Clinical presentation

History

Cocaine may produce toxicity in virtually any organ; few complaints (particularly focal complaints) can be dismissed
Chest pain, shortness of breath, headache, focal neurologic symptoms, and extremity symptoms are particularly worrisome

Physical examination

Vital signs: Hypertension and tachycardia almost universal; hyperthermia may occur
CNS: Agitation common; focal signs suggest cerebrovascular accident
Pupils: Mydriasis common
Lungs: Decreased breath sounds after smoking crack suggest pneumothorax
Extremities: Decreased pulses suggest vascular catastrophe, such as aortic dissection

Laboratory evaluation

General laboratory screening for poisoned patients

Fingerstick glucose
ECG
Acetaminophen and salicylate levels
Urine pregnancy test in females of childbearing age

Urine toxicology testing

Confirms cocaine use in last several days but does not confirm acute toxicity

Advanced testing

Driven by clinical symptoms (eg, cardiac biomarkers for suspected myocardial infarction; CT for suspected thoracic aortic dissection)

Treatment

Airway management

Succinylcholine relatively contraindicated in rapid sequence intubation; consider rocuronium (1 mg/kg IV) or other nondepolarizing agent as alternative

Psychomotor agitation

Administer benzodiazepines (eg, diazepam 5 to 10 mg IV every 3 to 5 minutes until agitation controlled)

Severe or symptomatic hypertension

Administer diazepam (5 mg IV) or lorazepam (1 mg IV); may repeat every 5 minutes until sedated
Phentolamine initial dose 1 to 2.5 mg IV; titrate to effect; may repeat every 5 to 15 minutes with doses up to 15 mg maximum
DO NOT ADMINISTER BETA BLOCKERS, INCLUDING LABETALOL. Beta blockade is contraindicated in acute cocaine toxicity.

Cocaine-associated myocardial ischemia

Obtain ECG (accuracy with cocaine-associated chest pain unclear; refer to UpToDate text)
Administer diazepam (5 mg IV) or lorazepam (1 mg IV) for agitation or hypertension; may repeat as necessary
Aspirin 325 mg orally (assuming aortic dissection not suspected)
Nitroglycerin 0.4 mg SL with or without continuous infusion
Phentolamine (see dosing above; hold for SBP <100)
DO NOT ADMINISTER BETA BLOCKERS, INCLUDING LABETALOL. Beta blockade is contraindicated in acute cocaine toxicity.

QRS widening on ECG (rare; suggests profound toxicity)

Administer sodium bicarbonate 1 to 2 mEq/kg IV push

Disposition

Patients with uncomplicated cocaine toxicity (agitation and sympathomimetic toxicity but no evidence of end-organ damage) may be treated with benzodiazepines and observed until symptoms resolve, then discharged.

Patients with cocaine-associated chest pain and a normal or unchanged ECG, in whom thoracic aortic dissection is not a concern, should be observed for 9 to 12 hours. If repeat cardiac biomarkers and a repeat ECG are normal, such patients may be discharged.

Patients with any evidence of end-organ toxicity should be admitted.

CNS: central nervous system; ECG: electrocardiogram; CT: computed tomography; IV: intravenously; SL: sublingually; SBP: systolic blood pressure.

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Cocaine toxicity: Rapid overview of emergency management