What tests and interventions are indicated for suspected laced cocaine ingestion in the ED?

From the Guidelines

For suspected laced cocaine ingestion in the ED, immediate tests and interventions should prioritize identifying and managing life-threatening complications, including cardiac and neurological issues, as recommended by the 2023 American Heart Association guidelines 1.

Initial Assessment and Testing

The following tests should be ordered immediately:

• Comprehensive urine drug screen to detect common drugs of abuse, including cocaine and other potential adulterants
• Serum electrolytes, BUN, creatinine to assess for electrolyte imbalances and kidney injury
• Complete blood count (CBC) to reveal any hematological abnormalities
• Liver function tests to assess for acute liver injury
• Electrocardiogram (ECG) to evaluate for cardiac complications
• Chest X-ray to identify any pulmonary complications

Management of Complications

According to the 2023 American Heart Association guidelines 1, management of life-threatening cocaine poisoning should include:

• Rapid external cooling for life-threatening hyperthermia
• Administration of sodium bicarbonate for wide-complex tachycardia or cardiac arrest
• Administration of lidocaine for wide-complex tachycardia
• Administration of vasodilators (e.g., nitrates, phentolamine, calcium channel blockers) for patients with cocaine-induced coronary vasospasm or hypertensive emergencies Additionally, closely monitoring vital signs, including blood pressure, heart rate, respiratory rate, and temperature, is crucial to promptly identify and manage acute complications such as hypertension, arrhythmias, or seizures. Consideration of activated charcoal may be beneficial if ingestion was recent and the airway is protected, as noted in previous studies 1.

Ongoing Care

The use of cocaine can be ascertained by self-reports or by urine analysis, with qualitative immunoassay detection of the cocaine metabolite benzoylecgonine in the urine being the most commonly used laboratory method 1. However, the primary focus should remain on managing potential life-threatening complications and providing supportive care to improve patient outcomes.

From the FDA Drug Label

Following an acute overdosage, toxicity may result from codeine or acetaminophen Clinical Presentation Codeine Acute overdosage with codeine can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia, hypotension, partial or complete airway obstruction, atypical snoring, and death Marked mydriasis rather than miosis may be seen with hypoxia in overdose situations. The opioid antagonists, naloxone or nalmefene, are specific antidotes to respiratory depression resulting from opioid overdose. Gastric decontamination with activated charcoal should be administered just prior to N-acetylcysteine (NAC) to decrease systemic absorption if acetaminophen ingestion is known or suspected to have occurred within a few hours of presentation

The FDA drug label does not answer the question about suspected laced cocaine ingestion in the ED. The provided labels discuss codeine and acetaminophen overdose, as well as naloxone administration, but do not mention cocaine.

From the Research

Initial Assessment and Management

• The patient with suspected laced cocaine ingestion should be managed with a systematic approach, starting with airway, breathing, and circulation (ABCs) stabilization 2.
• A thorough history, physical examination, and laboratory analysis, including vital signs, ECG, and imaging, should be performed to identify potential toxidromes and guide management 2.

Laboratory Tests and Interventions

• Patients with cocaine intoxication should be screened for rhabdomyolysis and acute kidney injury (AKI), as well as other drug toxicity, including alcohol 3.
• Laboratory tests, such as creatine kinase (CK) and serum creatinine, should be performed to assess for rhabdomyolysis and AKI 3.
• Aggressive measures, including intravenous hydration, should be taken to treat the underlying cause of AKI 3.
• In cases of severe rhabdomyolysis and AKI, patients may require hemodialysis and ongoing renal replacement therapy 3.

Anesthetic Management

• Patients with acute cocaine intoxication may require perioperative management, including a preoperative review of major organ systems 4.
• Nitroglycerin may be used to manage hypertension associated with coronary vasoconstriction, while controversy exists regarding the management of ventricular dysrhythmias and asystole 4.
• General anesthesia, including barbiturates, nitrous oxide, and opioids, may be used, but inhalational agents should be used with caution due to their myocardial depressant effects 4.
• Regional anesthesia may be a good choice if coagulopathies and hypovolemia are corrected 4.

Special Considerations

• Pediatric patients with suspected laced cocaine ingestion may present with sedation and acute encephalopathy, requiring intubation and supportive care 5.
• Laboratory confirmation of delta-8 tetrahydrocannabinol (delta-8 THC) exposure may be challenging due to cross-reactivity with other cannabinoids, and specialized testing may be required 5.