What is the initial management approach for an agitated patient due to cocaine use?

Management of Cocaine-Induced Agitation

Benzodiazepines are the first-line treatment for cocaine-induced agitation, controlling both the agitation itself and the associated cardiovascular toxicity (hypertension and tachycardia). 1

Initial Pharmacologic Approach

Administer benzodiazepines immediately as they address multiple cocaine toxicity mechanisms simultaneously:

• Lorazepam 2 mg IM/IV or diazepam 5-10 mg IM/IV are the preferred agents 1, 2
• Benzodiazepines treat agitation, hypertension, tachycardia, and chest discomfort through reduction of central nervous system stimulation 1
• The American Heart Association specifically recommends benzodiazepines as first-line for cocaine-induced hypertension, tachycardia, and agitation (Class IIa, Level of Evidence B) 1
• Repeat dosing every 15-30 minutes as needed until adequate sedation is achieved 2

Alternative or Adjunctive Agents

If benzodiazepines alone are insufficient after 2-3 doses:

• Haloperidol 5 mg IM can be added for persistent severe agitation 1, 3
• Droperidol 2.5-5 mg IM provides more rapid sedation than haloperidol if immediate control is required 1
• The combination of parenteral benzodiazepine plus haloperidol may produce more rapid sedation than monotherapy 1

Critical Safety Considerations

Absolutely avoid pure beta-blockers in cocaine-induced agitation:

• Beta-blockers cause unopposed alpha-adrenergic stimulation, leading to paradoxical coronary vasospasm and worsening hypertension 1, 2
• This contraindication applies for at least 72 hours after cocaine use 4, 2
• If beta-blockade is absolutely necessary, use combined alpha- and beta-blocking agents (labetalol) only after administering a vasodilator first 4

Refractory Hypertension or Chest Pain

If cardiovascular symptoms persist despite benzodiazepines:

• Nitroglycerin (sublingual or IV) for chest discomfort and hypertension 1
• Phentolamine (alpha-blocker) for severe hypertension or coronary vasospasm 1, 2
• Calcium channel blockers (verapamil) as an alternative vasodilator 1
• Morphine for chest pain and anxiety reduction 1

Monitoring Requirements

Continuously monitor vital signs and cardiac rhythm during treatment:

• Cocaine causes hypertension, tachycardia, and coronary vasospasm that require serial assessment 2
• Obtain 12-lead ECG to identify ST-segment changes or wide-complex tachycardia 2
• Screen for life-threatening complications: aortic dissection, coronary artery dissection, myocarditis 2

Dosing Pitfall to Avoid

Carefully dose all medications to prevent hypotension after cocaine metabolism:

• Cocaine's cardiovascular effects are transient (minutes to hours), but medication effects persist longer 1, 2
• Overly aggressive treatment can cause rebound hypotension once cocaine is metabolized 1
• Titrate medications to effect rather than giving maximum doses upfront 2

Duration of Benzodiazepine Therapy

Limit benzodiazepines to 7-14 days maximum to prevent secondary dependence:

• Short-term use (7-14 days) controls acute withdrawal symptoms without creating benzodiazepine addiction 5, 4
• Taper benzodiazepines as agitation resolves and transition to psychosocial interventions 5, 4

Wide-Complex Tachycardia Protocol

If QRS duration exceeds 120 ms (indicating sodium channel blockade):

• Sodium bicarbonate 1-2 mEq/kg IV bolus reverses cocaine's class Ic antiarrhythmic effects 1, 2
• Repeat boluses until hemodynamic stability is restored and QRS narrows to <120 ms 1
• This treatment is extrapolated from evidence with other sodium channel blockers (tricyclic antidepressants, flecainide) 1

Hyperthermia Management

If temperature is dangerously elevated (>40°C):

• Rapidly cool using evaporative or immersive cooling rather than cooling blankets 2
• Hyperthermia results from cocaine-induced hypermetabolism and significantly increases mortality 2
• Benzodiazepines also help reduce hyperthermia by decreasing muscle hyperactivity 2