What is the emergency treatment for severe chest pain due to cocaine overdose?

Emergency Treatment for Severe Chest Pain from Cocaine Overdose

For patients presenting with severe chest pain after cocaine use, immediately administer sublingual nitroglycerin or intravenous calcium channel blockers (diltiazem 20 mg IV), along with benzodiazepines for agitation and hypertension, while obtaining an ECG to guide further management. 1

Initial Assessment and Risk Stratification

Obtain an immediate 12-lead ECG to determine the presence of ST-segment elevation, which fundamentally changes management strategy. 1

• Patients with ST-segment elevation, ST-segment depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability require direct admission to monitored beds (approximately 24% will have MI and another 24% will have unstable angina). 1
• Most patients (approximately 94%) with cocaine-associated chest pain will NOT develop MI, but all require evaluation. 2, 3

Critical caveat: Young patients often have benign early repolarization that mimics ST-elevation, so only a small percentage with J-point elevation are actually having an MI. 1

First-Line Pharmacologic Management

For All Patients with Cocaine-Associated Chest Pain:

Benzodiazepines should be administered as first-line therapy to control agitation, tachycardia, and hypertension. 4, 5

Sublingual nitroglycerin or intravenous calcium channel blockers (diltiazem 20 mg IV) should be given immediately for chest pain. 1, 6

• Both agents reverse cocaine-induced coronary vasoconstriction, hypertension, and tachycardia. 1
• Nitroglycerin can be repeated every 5 minutes for up to 3 doses (15 minutes total). 6
• If pain persists after 3 nitroglycerin doses, this constitutes a medical emergency requiring immediate coronary angiography if available. 1, 6

Aspirin should be administered as part of standard acute coronary syndrome management. 1, 7

Critical Contraindication:

NEVER administer beta-blockers in acute cocaine intoxication (within 72 hours of use) due to risk of unopposed alpha-adrenergic stimulation causing severe coronary vasospasm. 4, 5

Management Based on ECG Findings

ST-Segment Elevation Present:

1. Administer sublingual nitroglycerin or IV calcium channel blockers immediately. 1

2. If no response to vasodilators, proceed immediately to coronary angiography if available. 1

3. PCI is strongly preferred over fibrinolytic therapy when available, as cocaine users frequently have contraindications to thrombolytics (hypertension, seizures, aortic dissection). 1, 4

4. If PCI is performed, use bare-metal stents rather than drug-eluting stents because cocaine users are unreliable with prolonged dual antiplatelet therapy adherence, creating high risk for in-stent thrombosis. 1, 4

5. Fibrinolytic therapy may be considered only if ST-elevation persists despite vasodilators, there are no contraindications, and coronary angiography is unavailable. 1

   • Warning: Case reports document higher rates of intracranial hemorrhage with fibrinolytics in cocaine users. 1

Normal ECG or Minimal T-Wave Changes:

1. Administer sublingual nitroglycerin or oral calcium channel blocker. 1

2. Observe in monitored setting for 9-12 hours with serial cardiac troponin measurements (preferred over CK-MB due to higher specificity). 1

   • Draw troponin at presentation and repeat at 6-hour intervals. 1
   • Cocaine can cause CK and CK-MB elevation from rhabdomyolysis without MI, making troponin I or T more reliable. 1

3. If troponins remain negative and patient is stable, discharge is safe for the majority of intermediate- and low-risk patients. 1

4. Stress testing is optional and can be performed during observation or as outpatient follow-up, depending on cardiac risk factors and ongoing symptoms. 1

ST-Depression or Isolated T-Wave Changes:

1. Administer nitroglycerin and calcium channel blockers. 1

2. If unresponsive to vasodilators, coronary angiography is recommended if available. 1

3. Admit to monitored bed for 24 hours with serial troponin measurements. 1

Additional Considerations

Screen for life-threatening complications beyond MI, including aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy, which are all reported with cocaine use. 1, 4

Monitor vital signs closely throughout the observation period, particularly in patients with history of cardiovascular complications. 4, 5

Avoid combined alpha- and beta-blocking agents (like labetalol) in the acute setting, though this may be reasonable in select circumstances (Class IIb recommendation). 1

For refractory cases with profound cardiogenic shock, extracorporeal membrane oxygenation (ECMO) should be considered when standard vasodilator therapy worsens systemic perfusion. 8