What are the features and management of a cocaine overdose?

Features and Management of Cocaine Overdose

Cocaine overdose presents with a sympathomimetic toxidrome requiring prompt recognition and treatment with benzodiazepines as first-line therapy, followed by targeted interventions for specific complications including sodium bicarbonate for wide-complex tachycardias and rapid cooling for hyperthermia. 1

Clinical Presentation

Cardiovascular Features

• Tachycardia and hypertension (predominant manifestations due to central nervous system stimulation) 1
• Chest pain and acute coronary syndromes 1
• Arrhythmias:
  • Wide-complex tachycardia (due to sodium channel blockade) 1
  • Ventricular tachycardia and ventricular fibrillation 1
  • Asystole 1
  • QRS prolongation and QT interval prolongation 1
  • Brugada-like ECG pattern in severe cases 2
• Coronary artery spasm 1
• Accelerated atherosclerosis in chronic users 1
• Aortic or coronary artery dissection 1

Neurological Features

• Agitation and psychomotor activity 1
• Seizures 1, 2
• Altered mental status 1

Other Features

• Hyperthermia (life-threatening) 1
• Diaphoresis 1
• Rhabdomyolysis 1
• Metabolic acidosis 2
• Methemoglobinemia (when cocaine is adulterated with benzocaine) 3
• Myocarditis and cardiomyopathy (with chronic use) 1

Management Algorithm

Initial Stabilization

1. Airway, Breathing, Circulation (ABC) assessment
2. Continuous cardiac monitoring and frequent vital signs
3. Obtain 12-lead ECG to assess for QRS prolongation, QT prolongation, and signs of ischemia

First-Line Interventions

1. Benzodiazepines (Class IIa, LOE B): First-line treatment for agitation, hypertension, tachycardia, and seizures 1, 4

   • Lorazepam or diazepam for control of hypertension, tachycardia, and agitation 1
   • May not always effectively mitigate all cardiovascular symptoms 4

2. Rapid external cooling (Class I, LOE C-LD) for life-threatening hyperthermia 1

   • Evaporative or immersive cooling preferred over cooling blankets 1

Management of Specific Complications

For Cardiovascular Complications

1. For wide-complex tachycardia or cardiac arrest:

   • Sodium bicarbonate (Class IIa, LOE C-LD): 1 mL/kg of 8.4% solution IV as bolus, repeated until hemodynamic stability is restored and QRS duration is ≤120 ms 1
   • Lidocaine (Class IIa, LOE C-LD): For wide-complex tachycardia 1

2. For coronary vasospasm or chest pain:

   • Vasodilators (Class IIa, LOE C-LD) 1:
     • Nitroglycerin (sublingual) 1
     • Calcium channel blockers (e.g., verapamil) 1, 4
     • Alpha-blockers (phentolamine) 1, 4
   • Morphine can be beneficial (Class IIa, LOE B) 1

3. For hypertensive emergency:

   • Benzodiazepines as first line 1
   • Vasodilators as listed above 1

For Cardiac Arrest

• Follow standard BLS and ACLS algorithms 1
• Consider sodium bicarbonate for persistent arrest 1
• Case series demonstrates 55% survival rate with standard therapy 1

Important Cautions

• AVOID beta-blockers (Class III, LOE C): May worsen coronary vasospasm and lead to unopposed alpha-adrenergic stimulation 1
• Carefully titrate medication doses to avoid hypotension after cocaine is metabolized 1
• Consider potential adulterants in street cocaine that may cause additional toxicity (e.g., benzocaine causing methemoglobinemia) 3, 5

Special Considerations

Pediatric Patients

• Similar management approach as adults 1
• Adjust medication doses based on weight 1

Chronic Cocaine Users

• May have accelerated coronary atherosclerosis 1
• Higher risk of myocarditis and cardiomyopathy 1
• Consider bare-metal stents over drug-eluting stents if PCI is needed (due to compliance concerns with dual antiplatelet therapy) 1

Laboratory Assessment

• Cardiac biomarkers (troponin preferred over CK-MB due to potential skeletal muscle injury) 1
• Comprehensive metabolic panel
• Arterial blood gas (to assess for metabolic acidosis) 2
• Consider methemoglobin level if cyanosis persists despite oxygen therapy 3

By promptly recognizing the features of cocaine overdose and implementing appropriate management strategies, clinicians can significantly reduce morbidity and mortality associated with this potentially life-threatening condition.