Management of Cocaine Intoxication with Gastrointestinal and Neurological Symptoms
This patient requires immediate evaluation for mesenteric ischemia and aggressive supportive care with benzodiazepines as first-line therapy, while avoiding beta-blockers. The constellation of abdominal pain, nausea, vomiting, and neurological symptoms (tingling) following cocaine use raises serious concern for nonocclusive mesenteric ischemia, a life-threatening complication that demands urgent intervention 1.
Immediate Assessment and Stabilization
Primary Concerns
Suspect nonocclusive intestinal ischemia in any patient using cocaine who develops abdominal pain 1. Cocaine causes inappropriate mesenteric arterial vasospasm through its potent sympathomimetic effects, leading to bowel ischemia even without arterial occlusion 1, 2.
The tingling sensation represents cocaine's sympathomimetic overstimulation and should be treated alongside other acute symptoms 2, 3.
First-Line Pharmacologic Management
Administer benzodiazepines immediately as first-line therapy for hypertension, tachycardia, agitation, and the overall sympathetic neural storm 4, 5. Benzodiazepines counteract cocaine's excessive adrenergic stimulation without the risks associated with beta-blockade 4.
Add nitroglycerin or calcium channel blockers (such as diltiazem 20 mg IV) for persistent hypertension or ongoing symptoms 4, 5. These vasodilators help reverse cocaine-induced vasoconstriction affecting multiple organ systems 5.
Absolutely avoid beta-blockers in acute cocaine intoxication due to the risk of unopposed alpha-adrenergic stimulation causing worsened coronary and mesenteric vasospasm 4, 5. This is a critical pitfall that can worsen ischemia 5.
Antiemetic Therapy
- Administer ondansetron for nausea and vomiting, which is safe and effective for symptomatic relief 6. Standard dosing applies, with monitoring for serotonin syndrome in the context of cocaine's effects on neurotransmitter systems 6.
Diagnostic Evaluation for Mesenteric Ischemia
When to Pursue Arteriography
If abdominal pain and gastrointestinal symptoms do not improve rapidly with initial supportive treatment, proceed urgently to arteriography 1. This is the gold standard for diagnosing nonocclusive mesenteric ischemia and demonstrates characteristic mesenteric arterial vasospasm 1.
Treatment of the underlying sympathetic overstimulation is the most important initial step, but persistent symptoms despite aggressive medical management mandate angiographic evaluation 1.
Interventional Options
Transcatheter administration of vasodilator medications directly into areas of vasospasm is indicated for cocaine-induced intestinal ischemia that does not respond to systemic supportive treatment 1. This approach is especially appropriate in drug-induced nonocclusive ischemia where systemic shock may not coexist 1.
Laparotomy with resection of nonviable bowel is indicated if symptoms persist despite medical and interventional treatment 1. Do not delay surgical consultation if there are signs of peritonitis or clinical deterioration 1.
Cardiac Evaluation
Risk Stratification
Obtain ECG and serial cardiac troponins to evaluate for concurrent myocardial ischemia or infarction 1, 5. While only 0.7-6% of cocaine-associated chest pain represents true MI, the consequences of missing it are severe 5.
High-risk features include ST-segment changes ≥1mm, elevated troponin, recurrent chest pain, or hemodynamic instability 5.
Observation Protocol
- Low to intermediate-risk patients without concerning abdominal findings can be managed in an observation unit for 9-12 hours with continuous ECG monitoring and repeat troponin measurements 1, 5. However, this patient's significant gastrointestinal symptoms likely preclude simple observation 1.
Monitoring Strategy
Serial Assessments
Continuously monitor vital signs, with particular attention to blood pressure, heart rate, and temperature 4. Cocaine causes intense sympathomimetic effects that require ongoing surveillance 2, 3.
Reassess abdominal examination frequently for development of peritoneal signs, which would indicate bowel infarction requiring immediate surgical intervention 1.
Monitor for neurological deterioration, including seizures, which represent severe cocaine toxicity 2, 7, 3.
Critical Pitfalls to Avoid
Never use beta-blockers acutely, as unopposed alpha-stimulation worsens vasospasm in coronary, mesenteric, and other vascular beds 4, 5.
Do not dismiss abdominal pain as simple gastritis or nausea—cocaine-induced mesenteric ischemia can progress rapidly to bowel infarction and death if not recognized 1.
Do not rely on CK or CK-MB for cardiac evaluation, as these can be elevated from skeletal muscle activity and rhabdomyolysis after cocaine use; troponin is the preferred biomarker 5.
Recognize that cocaine causes multiorgan toxicity through oxidative stress, mitochondrial dysfunction, and direct toxic effects beyond just sympathetic stimulation 2. The patient requires comprehensive evaluation, not just treatment of individual symptoms 2, 3.