Signs of Acute Cocaine Intoxication
Acute cocaine intoxication presents with a characteristic sympathomimetic toxidrome marked by tachycardia, hypertension, hyperthermia, seizures, diaphoresis, and increased psychomotor activity due to cocaine's effects on catecholamine reuptake inhibition. 1
Cardiovascular Signs
- Tachycardia (increased heart rate) due to postsynaptic β-adrenergic receptor agonism 1
- Hypertension (elevated blood pressure) due to peripheral postsynaptic α-adrenergic receptor agonism 1
- Coronary vasospasm which may lead to chest pain and myocardial ischemia 2
- ECG changes including QRS prolongation and QT interval prolongation due to cardiac sodium and potassium channel blockade 1
- Dysrhythmias including wide-complex tachycardia, ventricular tachycardia, and in severe cases, asystolic cardiac arrest 1
Neurological and Psychiatric Signs
- Euphoria - a key sign of acute intoxication 1
- Increased psychomotor activity and agitation 1, 3
- Seizures, which are a major determinant of lethality in cocaine poisoning 4, 3
- Paranoia (occurs in 68% to 84% of patients using cocaine) 5
- Hallucinations and delusions 5
- Violent behavior (occurs in up to 55% of patients with cocaine-induced psychiatric symptoms) 5
Other Physical Signs
- Hyperthermia, which can be rapidly life-threatening and requires immediate intervention 1, 3
- Diaphoresis (excessive sweating) 1, 3
- Mydriasis (dilated pupils) 6
- Respiratory and metabolic acidosis in severe cases 4
Laboratory Findings
- Patients may show electrocardiographic evidence of cardiac ischemia without necessarily having elevations in cardiac enzymes 3
- Metabolic acidosis may be present in severe cases 4
Treatment Considerations
- Benzodiazepines are the mainstay of initial management for hypertension, tachycardia, and agitation 1, 6
- Beta-blockers should be avoided in acute intoxication due to risk of potentiating coronary spasm through unopposed alpha stimulation 1
- Rapid external cooling is recommended for life-threatening hyperthermia 1
- Sodium bicarbonate administration is reasonable for wide-complex tachycardia or cardiac arrest 1
- Vasodilators (nitrates, phentolamine, calcium channel blockers) are reasonable for cocaine-induced coronary vasospasm or hypertensive emergencies 1
Common Pitfalls and Caveats
- Failing to recognize that beta-blockers are contraindicated in acute cocaine intoxication as they may worsen coronary vasospasm 1
- Underestimating the risk of hyperthermia, which requires aggressive management 1
- Missing the diagnosis in young patients presenting with acute myocardial infarction without traditional risk factors 2
- Overlooking the possibility of subclinical status epilepticus, which can be fatal 3
- Not addressing both cardiovascular and neurological manifestations simultaneously 3
Early recognition of these signs and appropriate management focusing on benzodiazepines for initial control, avoiding beta-blockers, and addressing specific complications can significantly improve outcomes in patients with acute cocaine intoxication.