What is the treatment for a cocaine overdose?

Treatment of Cocaine Overdose

The treatment of cocaine overdose requires immediate management of cardiovascular symptoms with benzodiazepines as first-line therapy, followed by targeted interventions for specific complications such as hypertension, chest pain, and arrhythmias. 1

Initial Assessment and Stabilization

• Assess and stabilize ABCs (Airway, Breathing, Circulation)
• Obtain vital signs, including temperature (hyperthermia requires aggressive treatment)
• Establish IV access
• Cardiac monitoring
• Obtain 12-lead ECG to assess for ischemia or arrhythmias

Primary Pharmacological Management

First-Line Treatment:

• Benzodiazepines (lorazepam, diazepam) for:
  • Agitation
  • Hypertension
  • Tachycardia
  • Seizures
  • Chest pain
  • Class IIa recommendation 1

Cardiovascular Complications Management:

For hypertension or chest pain:

• Benzodiazepines (first-line)
• Nitroglycerin (sublingual or IV) - Class IIa recommendation 1
• Morphine - may be beneficial for chest pain 1
• Calcium channel blockers (e.g., diltiazem 20 mg IV) for coronary vasospasm 1
• Phentolamine (alpha-blocker) may be considered for severe hypertension - Class IIb 1

Important caution:

• DO NOT administer beta-blockers - contraindicated in cocaine toxicity (Class III recommendation) 1
  • Can worsen coronary vasoconstriction by allowing unopposed alpha-adrenergic stimulation

Management of Specific Complications

For ventricular arrhythmias:

• Sodium bicarbonate (1-2 mEq/kg IV bolus) - Class IIb recommendation 1
  • Especially for wide-complex tachycardias
  • May repeat until hemodynamic stability is restored and QRS duration is ≤120 ms
• Consider lidocaine bolus followed by infusion for arrhythmias secondary to myocardial ischemia - Class IIb 1

For seizures:

• Benzodiazepines (diazepam or lorazepam) - first-line therapy 2
• Control of seizures is critical for survival and preventing further complications

For acidosis:

• Sodium bicarbonate administration for metabolic acidosis
• Ensure adequate ventilation for respiratory acidosis
• Correction of acidosis can help normalize cardiac rhythm 2

For hyperthermia:

• Aggressive cooling measures
• Hyperthermia increases toxicity and should be treated promptly 1

Cardiac Complications Management

For suspected myocardial ischemia with ST-elevation:

1. Administer sublingual nitroglycerin or calcium channel blocker
2. If no response, consider immediate coronary angiography 1
3. For revascularization:
   • PCI preferred over fibrinolysis when available
   • If stenting is necessary, 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 unavailable and no contraindications exist

For non-ST elevation chest pain:

• Observe in monitored setting for 24 hours (most complications occur within this timeframe)
• Serial cardiac biomarkers (troponin preferred over CK-MB due to specificity)
• Consider shorter observation (9-12h) with troponin measurements at 3,6, and 9 hours 1

Monitoring and Disposition

• Cardiac monitoring for at least 24 hours for patients with ECG changes
• If clinical condition and ECG remain unchanged after observation period, patient may be discharged
• Consider psychiatric evaluation and substance abuse treatment referral prior to discharge

Common Pitfalls to Avoid

1. Using beta-blockers for hypertension or tachycardia (can worsen coronary vasospasm)
2. Failing to treat seizures aggressively (major determinant of mortality)
3. Neglecting to correct acidosis (contributes to cardiac dysfunction)
4. Discharging patients too early (complications may develop within 24 hours)
5. Overlooking the possibility of polysubstance use (may complicate clinical picture)
6. Underestimating the risk of aortic or coronary dissection in severe cases

The management of cocaine overdose requires prompt recognition and treatment of life-threatening complications while avoiding therapies that may worsen the patient's condition. Benzodiazepines remain the cornerstone of initial management, with additional targeted therapies based on specific complications.