Management of Cocaine Overdose
The management of cocaine overdose should prioritize benzodiazepines as first-line treatment, with continuous monitoring of vital signs and targeted interventions for specific complications such as hypertension, hyperthermia, and arrhythmias. 1
Initial Assessment and Stabilization
- Vital Sign Monitoring: Immediately check temperature, heart rate, blood pressure, and assess level of consciousness and agitation 1
- Airway Management: Secure airway if consciousness is impaired
- Seizure Control: Administer benzodiazepines IV for seizure activity
- Cardiac Monitoring: Continuous ECG monitoring to detect arrhythmias
Pharmacological Management
First-Line Treatment
- Benzodiazepines: Administer IV in titrated doses 1
- Start with 2 mg IV midazolam in benzodiazepine-naïve patients
- Follow with 1 mg/h infusion if needed
- For difficult IV access in combative patients, consider ketamine IM
Cardiovascular Complications
- Hypertension: Use vasodilators such as nitrates or calcium channel blockers 1
- Arrhythmias: Administer sodium bicarbonate or lidocaine for ventricular tachycardia 1
- Coronary Vasospasm: Use nitroglycerin or other vasodilators 1
Important Contraindications
- Avoid non-selective beta-blockers as they may worsen coronary vasospasm due to unopposed alpha stimulation 1
- Caution with labetalol as its beta-blocking effects are more potent than alpha-blocking effects, potentially worsening vasoconstriction 2
Management of Specific Complications
Hyperthermia
- Implement rapid external cooling measures 1
- Monitor core temperature continuously
Seizures
- Use IV diazepam or lorazepam as first-line treatment 1
- Prepare for potential status epilepticus
Severe Cardiovascular Toxicity
- Consider intravenous lipid emulsion therapy for refractory cardiovascular instability 3
- This approach has shown promising results in case reports of severe cocaine toxicity with hemodynamic compromise 4
Ongoing Monitoring and Support
- Continuous monitoring of oxygen saturation, cardiac activity, blood pressure 1
- Use capnography when available
- Adjust sedation by administering additional benzodiazepines for persistent agitation 1
- Monitor for psychiatric complications during withdrawal 1
Transportation Considerations
- Maintain continuous monitoring during transport 1
- Ensure emergency equipment is readily available
- Communicate with receiving facility about patient status and interventions 1
Pitfalls and Caveats
- Prolonged physical restraint may increase blood pressure, intracranial pressure, and promote bleeding 1
- Lidocaine, while used for arrhythmias, may have additive effects with cocaine and potentially lower seizure threshold 2
- The use of epinephrine in cocaine-induced cardiac arrest is controversial due to already elevated catecholamine levels 2