What is the treatment for a cocaine overdose?

Treatment for Cocaine Overdose

Benzodiazepines are the first-line treatment for cocaine overdose, followed by targeted therapy for specific symptoms including calcium channel blockers or nitroglycerin for cardiovascular complications. 1

Initial Management

Cocaine overdose requires prompt intervention with a focus on addressing both cardiovascular and neurological toxicity:

1. Airway, Breathing, Circulation (ABC) - Standard resuscitation protocols should be followed for patients in cardiac arrest 1

2. First-line medication: Benzodiazepines

   • Administer lorazepam or diazepam to control agitation, hypertension, tachycardia, and prevent seizures 1, 2
   • Benzodiazepines help counteract central nervous system stimulation and have been shown to be beneficial (Class IIa, LOE B) 1

3. Temperature control

   • Aggressively treat hyperthermia, which increases toxicity 1
   • Use cooling measures for elevated temperature

Cardiovascular Complications Management

For patients with chest pain, hypertension, or other cardiovascular symptoms:

• Nitroglycerin - Sublingual or IV for coronary vasospasm (Class IIa, LOE B) 1
• Calcium channel blockers - Diltiazem 20 mg IV for chest pain with myocardial ischemia 1
• Phentolamine - Consider for severe hypertension (Class IIb, LOE B) 1
• Morphine - Can be beneficial for chest pain and hypertension 1

Important caution:

• Avoid beta-blockers - These are contraindicated as they may worsen coronary vasospasm and lead to unopposed alpha-adrenergic stimulation (Class III, LOE C) 1

Arrhythmia Management

For wide-complex tachycardia or ventricular arrhythmias:

• Sodium bicarbonate - Administer 1 mL/kg of 8.4% solution IV as a bolus for wide-complex tachycardia 1
• Repeat sodium bicarbonate as needed until hemodynamic stability is restored and QRS duration is ≤120 ms 1
• Consider lidocaine for ventricular arrhythmias secondary to myocardial infarction 1

Monitoring and Observation

• ECG monitoring - All patients should have continuous cardiac monitoring
• Observation period - Patients with normal ECG or minimal T-wave changes should be observed for 9-12 hours with troponin measurements at 3,6, and 9 hours 1
• Extended monitoring - Patients with ST-segment changes but normal cardiac biomarkers should be observed for 24 hours in a monitored bed 1

Special Considerations

Myocardial infarction management:

• If ST-elevation MI is present and no response to initial therapy:
  • Primary PCI is preferred over fibrinolysis due to frequent contraindications to fibrinolytics in cocaine users 1
  • Bare-metal stents are preferred over drug-eluting stents due to compliance concerns with dual antiplatelet therapy 1
  • Fibrinolytic therapy may be considered if PCI is unavailable and no contraindications exist 1

Seizure management:

• Diazepam is effective for controlling seizures, which are a major determinant of lethality in cocaine poisoning 2
• Control of seizures can help normalize cardiac rhythm and function 2

Pitfalls to Avoid

1. Misdiagnosis - Young patients presenting with chest pain or MI should be questioned about cocaine use 3

2. Beta-blocker administration - Can worsen coronary spasm and decrease coronary blood flow 3

3. Inadequate monitoring - Most complications occur within 24 hours, requiring appropriate observation periods 1

4. Overlooking acidosis - Severe acidosis should be treated aggressively as it contributes to cardiac dysrhythmias 2

5. Misinterpreting elevated CK/CK-MB - May be elevated due to increased motor activity and rhabdomyolysis rather than MI; troponin is more specific 1