What is the treatment for cocaine toxicity?

Treatment of Cocaine Toxicity

For acute cocaine toxicity, immediately administer benzodiazepines as first-line treatment for cardiovascular and neurological manifestations, aggressively cool any hyperthermia with rapid external cooling methods, and reserve sodium bicarbonate and lidocaine for wide-complex tachycardia or cardiac arrest. 1, 2

Immediate Stabilization and Life-Threatening Complications

Hyperthermia Management

• Rapidly cool patients with life-threatening hyperthermia using evaporative or immersive cooling modalities, as these reduce temperature faster than cooling blankets or cold packs 1
• Hyperthermia results from cocaine-induced hypermetabolism and significantly increases toxicity and mortality 1
• Monitor core body temperature continuously in severe cases 1, 3

Cardiovascular Toxicity

• Administer benzodiazepines (lorazepam or diazepam) as first-line treatment for hypertension, tachycardia, chest pain, and agitation 2
• Add sublingual or IV nitroglycerin for persistent chest pain or hypertension 2
• Phentolamine (an alpha-adrenergic antagonist) is reasonable for cocaine-induced coronary vasospasm or hypertensive emergencies 1
• Calcium channel blockers (diltiazem 20 mg IV or verapamil) can be used for persistent cardiovascular instability 2
• Never administer pure beta-blockers in acute cocaine intoxication, as they cause unopposed alpha-adrenergic stimulation leading to paradoxical coronary vasospasm 1, 2

Cardiac Arrhythmias and Arrest

• Apply standard BLS and ACLS algorithms without modification for cocaine-induced cardiac arrest 2
• For wide-complex tachycardia or cardiac arrest, administer sodium bicarbonate (1-2 mEq/kg IV bolus) to reverse sodium channel blockade 1
• Lidocaine is reasonable for wide-complex tachycardia, as it competitively binds cocaine at sodium channels and reverses QRS prolongation 1
• Lidocaine bolus followed by infusion may prevent arrhythmias secondary to myocardial infarction 1

Seizure Management

• Control seizures immediately with diazepam, as seizures are a major determinant of lethality in cocaine poisoning 3
• Seizure control combined with correction of acidosis can normalize cardiac rhythm and function 3
• Maintain arterial blood pH >7.45 with sodium bicarbonate if severe acidosis is present 1, 3

Acute Coronary Syndrome Protocol

Risk Stratification

• Obtain immediate 12-lead ECG to identify ST-segment elevation 2
• High-risk features requiring monitored admission include: ST-elevation or depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability 2
• Use troponin I and T as preferred biomarkers over CK-MB, since CK can be falsely elevated from skeletal muscle activity and rhabdomyolysis 2
• Only 0.7-6% of patients with cocaine-associated chest pain actually have myocardial infarction 2

ST-Elevation MI Management

• Proceed immediately to PCI rather than fibrinolytic therapy, as cocaine users frequently have contraindications to thrombolytics 2
• Use bare-metal stents rather than drug-eluting stents due to shorter required duration of dual antiplatelet therapy and poor medication adherence in this population 2
• Administer morphine for chest discomfort 2

Low-Risk Patient Management

• Patients without high-risk features can be safely managed in a chest pain observation unit for 9-12 hours with clinical and ECG monitoring plus repeat troponin measurements 2

Monitoring and Screening

Essential Assessments

• Screen for life-threatening complications beyond MI: aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy 2
• Serial vital sign assessment is crucial in patients with cardiovascular complications 2
• Monitor for delayed complications, as toxicity can persist over 16 hours from ingestion 4

Refractory Cases

• Consider external pacing for bradyarrhythmias refractory to medical intervention 4
• Prompt consultation with a medical toxicologist is strongly recommended for severe cases 2

Critical Pitfalls to Avoid

• Carefully dose medications to avoid hypotension after cocaine metabolism, as cocaine's effects are transient but treatment effects persist 2
• Avoid beta-blockers within 72 hours of cocaine use due to risk of potentiating coronary vasospasm 5, 2
• The combination of cocaine with alcohol or cigarettes intensifies cardiovascular effects 2
• Evaluate and treat coexisting psychiatric disorders (depression, anxiety, bipolar disorder) that are common in cocaine users 5