What is the initial management for a patient with a cocaine overdose and a Glasgow Coma Scale (GCS) score of 15?

Management of Cocaine Overdose with GCS 15

Benzodiazepines are the cornerstone of initial management for a cocaine overdose patient with GCS 15, addressing agitation, hypertension, tachycardia, and preventing seizures through their anxiolytic and sedative effects. 1

Initial Assessment and Monitoring

Immediate evaluation priorities:

• Obtain ECG immediately to assess for QRS prolongation, wide-complex tachycardia, or QT prolongation from cocaine's sodium and potassium channel blockade 1
• Monitor vital signs continuously, particularly blood pressure, heart rate, and temperature, as cocaine produces a sympathomimetic toxidrome with tachycardia, hypertension, and potential hyperthermia 1
• Assess for chest pain or cardiac symptoms, as cocaine causes coronary vasospasm and can precipitate acute coronary syndrome even in young patients 1
• Check core temperature to identify life-threatening hyperthermia, which requires immediate intervention 1

Primary Pharmacologic Management

Benzodiazepines (First-Line):

• Administer benzodiazepines (diazepam or lorazepam) as the mainstay therapy for blood pressure control, psychomotor agitation, tachycardia, and seizure prevention 1, 2
• Titrate to effect for agitation and cardiovascular symptoms 1
• Can be used short-term (7-14 days) to manage acute withdrawal symptoms including craving and insomnia 2

Specific Complications and Treatments

For Hypertension and Chest Pain:

• If severe hypertension or chest pain persists despite benzodiazepines, administer vasodilators including nitroglycerin, calcium channel blockers (e.g., diltiazem), or phentolamine (α1-adrenergic antagonist) 1
• These agents counteract cocaine-induced coronary vasospasm and improve coronary blood flow 1

For Hyperthermia:

• If temperature is dangerously elevated, implement rapid external cooling immediately using evaporative or immersive cooling methods, which are more effective than cooling blankets 1
• Hyperthermia can be rapidly life-threatening and requires aggressive intervention 1

For Cardiac Arrhythmias:

• If wide-complex tachycardia develops, administer sodium bicarbonate (hypertonic solution) to reverse sodium channel blockade 1
• Lidocaine is also reasonable for wide-complex tachycardia, as it competitively binds cocaine at sodium channels and reverses QRS prolongation 1

Critical Medication Contraindications

Avoid Beta-Blockers:

• Never administer pure beta-blockers (e.g., propranolol, metoprolol) within 72 hours of cocaine use, as they cause unopposed alpha-adrenergic vasoconstriction, potentially worsening coronary vasospasm and hypertension 1, 2, 3
• If combined alpha/beta blockade is considered (e.g., labetalol), it may only be reasonable if a vasodilator has been given within the previous hour AND systolic BP >150 mmHg or heart rate >100 bpm 1
• However, labetalol's beta-blocking effects are more potent than its alpha-blocking effects, risking unopposed vasoconstriction 3

Cardiac Evaluation Protocol

For patients with chest pain or ECG changes:

• Administer aspirin, nitroglycerin, and benzodiazepines as initial therapy 1
• If ST-segment elevation persists after nitroglycerin and calcium channel blockers, proceed to immediate coronary angiography if available 1
• Serial cardiac biomarkers are less reliable in cocaine users, so maintain high clinical suspicion 4
• If ST-segment depression or T-wave changes persist despite medical therapy, coronary angiography is probably indicated 1

Observation and Disposition

For GCS 15 patients without complications:

• Monitor for at least 6-12 hours, as cocaine's half-life is relatively short but complications can develop 5
• Assess for psychiatric comorbidities (depression, anxiety, bipolar disorder) which are common in cocaine users 2
• Consider naltrexone (50 mg/day) for craving reduction and relapse prevention in appropriate candidates 2

Key Clinical Pitfalls

• Do not use class Ia or Ic antiarrhythmics, as cocaine already causes similar sodium channel blockade 1
• Avoid epinephrine in cardiac arrest scenarios when possible, given the existing catecholamine excess state 3
• Never discharge without adequate observation period, as delayed cardiovascular complications can occur 5, 4
• Screen for co-ingestions, as polysubstance use is common and complicates management 6