What is the immediate management for a patient with cocaine intoxication?

Immediate Management of Cocaine Intoxication

Benzodiazepines are the first-line treatment for cocaine intoxication, administered IV in titrated doses (starting with 2 mg IV midazolam in benzodiazepine-naïve patients), with careful monitoring to avoid respiratory depression. 1

Initial Assessment and Stabilization

1. Vital Sign Monitoring:

   • Check temperature, heart rate, blood pressure, oxygen saturation
   • Establish continuous cardiac monitoring and capnography if available
   • Assess level of consciousness and agitation

2. Sedation Protocol:

   • Start with 2 mg IV midazolam in benzodiazepine-naïve patients
   • Follow with 1 mg/h infusion if needed for ongoing agitation
   • For difficult IV access in combative patients, consider ketamine IM as an alternative 1

3. Cardiovascular Management:

   • For hypertension and coronary vasospasm: Use vasodilators (nitrates, calcium channel blockers)
   • For ventricular arrhythmias: Administer sodium bicarbonate or lidocaine 1
   • IMPORTANT: Avoid non-selective beta-blockers as they may worsen coronary vasospasm due to unopposed alpha stimulation 1, 2

Management of Specific Complications

1. Hyperthermia:

   • Implement rapid external cooling measures 1
   • Monitor core temperature continuously

2. Seizures:

   • Administer IV diazepam or lorazepam as first-line treatment 1
   • Ensure airway protection if seizures are prolonged

3. Coronary Vasospasm/Chest Pain:

   • Administer nitroglycerin or calcium channel blockers 1, 2
   • Monitor for ECG changes suggesting myocardial infarction 3
   • Be cautious with nitroglycerin as it may cause severe hypotension and reflex tachycardia 2

4. Severe Agitation:

   • Titrate benzodiazepines to effect
   • Avoid prolonged physical restraint which may increase blood pressure, intracranial pressure, and promote bleeding 1

Special Considerations

• Combined Intoxications: Cocaine may be mixed with other substances, complicating the clinical picture and treatment approach 4

• Cardiovascular Complications: Be vigilant for life-threatening arrhythmias and myocardial infarction, which may require specialized interventions 3

• Alternative Agents for Refractory Cases:

  • Combined β/α-blockers (labetalol, carvedilol) may be effective for both hypertension and tachycardia with fewer adverse events than selective beta-blockers 2
  • Dexmedetomidine (α2-agonist) has shown success in limited studies 2

• Differential Diagnosis: Consider that cocaine intoxication can mimic other conditions with sympathomimetic effects, such as thyroid storm 5

Monitoring and Disposition

• Continuous monitoring of vital signs throughout treatment
• Observe for at least 6 hours after symptom resolution
• Consider admission for patients with significant cardiovascular complications, persistent symptoms, or comorbidities

Remember that cocaine's cardiovascular effects can be severe and potentially fatal. The cornerstone of management is benzodiazepines to reduce sympathetic drive, with careful attention to cardiovascular complications and avoidance of non-selective beta-blockers.