What is the management of cardiac arrest due to cocaine toxicity?

Management of Cardiac Arrest Due to Cocaine Toxicity

Standard resuscitation algorithms should be followed for cardiac arrest due to cocaine toxicity, with specific adjunctive therapies implemented in the post-resuscitation phase for managing cardiovascular toxicity. 1

Initial Management

• Follow standard Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) algorithms for cardiac arrest management
• There is no evidence supporting cocaine-specific interventions during the cardiac arrest itself 1
• High-quality CPR and early defibrillation remain the cornerstone of management

Post-Resuscitation Pharmacological Management

First-Line Therapy

• Benzodiazepines (Class IIa, LOE B) 2
  • Diazepam 5-10 mg IV/IM or lorazepam 2-4 mg IV/IM
  • Repeat every 5-15 minutes until adequate sedation
  • Counteracts sympathomimetic effects and reduces cardiovascular complications
  • Helps manage agitation, hypertension, and tachycardia

Management of Specific Complications

1. For wide-complex tachycardia or QRS prolongation 2, 3

   • Sodium bicarbonate 1-2 mEq/kg IV bolus (Class IIa, LOE C-LD)
   • Lidocaine can be considered for persistent ventricular arrhythmias

2. For coronary vasospasm or chest pain 1, 2

   • Nitroglycerin (sublingual or IV) (Class IIa, LOE B)
   • Calcium channel blockers (verapamil) (Class IIb, LOE B)
   • Morphine (Class IIa, LOE B)
   • Alpha-blockers (phentolamine) (Class IIb, LOE B)

3. For hyperthermia 2

   • Rapid external cooling (Class I, LOE C-LD)
   • Continue benzodiazepines to reduce muscle activity

4. For severe hypertension 1, 2

   • Combination of benzodiazepines with nitroglycerin
   • Calcium channel blockers can be considered

Important Cautions

• AVOID BETA-BLOCKERS (Class III, LOE C) 2

  • Can worsen coronary vasospasm through unopposed alpha stimulation
  • Exception: Combined alpha/beta blockers like labetalol or carvedilol may be used cautiously 4

• Monitor for respiratory depression with benzodiazepines 2

Diagnostic Evaluation

• 12-lead ECG to assess for:
  • QRS prolongation
  • QT prolongation
  • Signs of ischemia or infarction
• Cardiac biomarkers (troponin)
• Comprehensive metabolic panel
• Arterial blood gas

Prognosis

• Interestingly, patients with cocaine-associated cardiac arrest have shown better neurologic recovery (55%) compared to age-matched controls (17%) 5
• This may be due to the younger age of cocaine users and potentially different mechanisms of arrest

Special Considerations

• Acidemia can worsen cocaine cardiotoxicity by promoting conduction delays and dysrhythmias 3
• Cocaine overdose manifestations include tachycardia, myocardial infarction, agitation, tremor, hyperpyrexia, and rhabdomyolysis 6
• Cocaine acts as a Vaughan-Williams class Ic antiarrhythmic in severe overdose, producing wide-complex tachycardia through blockade of cardiac sodium channels 1

Knowledge Gaps

• Controlled clinical trials are needed to advance the treatment of cardiac arrest and cardiotoxicity due to cocaine 1
• Future studies should evaluate the role of sodium bicarbonate, lidocaine, and other antiarrhythmic drugs in the treatment of cocaine-associated ventricular tachycardia 1