What is the management approach for cocaine intoxication?

Management of Cocaine Intoxication

Benzodiazepines are the cornerstone of initial management for cocaine intoxication, addressing hypertension, tachycardia, agitation, and psychomotor symptoms through their sedative and anxiolytic effects. 1, 2

Immediate Stabilization

Benzodiazepines as First-Line Therapy

• Administer lorazepam or diazepam immediately for hypertension, tachycardia, chest pain, agitation, and seizures—this is the mainstay of initial management. 1, 2
• Benzodiazepines control the sympathomimetic toxidrome by reducing catecholamine-driven cardiovascular effects and CNS stimulation. 1
• For seizures specifically, diazepam is first-line, with midazolam as an alternative. 3

Life-Threatening Hyperthermia

• Implement rapid external cooling using evaporative or immersive cooling modalities for life-threatening hyperthermia (Class I recommendation). 1, 2
• Evaporative or immersive methods reduce temperature faster than cooling blankets, cold packs, or endovascular devices. 1, 2
• Hyperthermia results from cocaine-induced hypermetabolism and significantly increases mortality. 2

Cardiovascular Complications

Hypertensive Emergency and Coronary Vasospasm

• Use vasodilators (nitroglycerin, phentolamine, or calcium channel blockers) for cocaine-induced coronary vasospasm or hypertensive emergencies. 1, 2
• Phentolamine (alpha-adrenergic antagonist) is particularly effective for coronary vasospasm. 2
• Avoid pure beta-blockers as they cause unopposed alpha-adrenergic stimulation, leading to paradoxical coronary vasospasm and worsening hypertension. 1, 2, 4
• If beta-blockade is absolutely necessary, use combined alpha- and beta-blocking agents (labetalol) only after administering a vasodilator within the previous hour. 4

Wide-Complex Tachycardia and Cardiac Arrest

• Administer sodium bicarbonate (1-2 mEq/kg IV bolus) for wide-complex tachycardia or cardiac arrest from cocaine poisoning (Class IIa recommendation). 1, 2
• Sodium bicarbonate reverses sodium channel blockade that causes QRS prolongation and dysrhythmias. 1, 2
• Lidocaine is reasonable for wide-complex tachycardia as it competitively binds cocaine at sodium channels and reverses QRS prolongation (Class IIa recommendation). 1, 2
• Apply standard BLS and ACLS algorithms without modification for cocaine-induced cardiac arrest. 2

Acute Coronary Syndrome Management

Initial Assessment

• Obtain immediate 12-lead ECG to identify ST-segment elevation or depression. 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
• High-risk features requiring monitored admission include: ST-elevation or depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability. 2

ST-Elevation MI Protocol

• 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

Screening for Complications

• Screen for life-threatening complications beyond MI: aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy. 2
• Monitor serial vital signs closely in patients with cardiovascular complications. 2, 4

Critical Pitfalls to Avoid

• Carefully dose medications to avoid hypotension after cocaine metabolism, as cocaine's effects are transient (minutes to hours) but treatment effects persist longer. 2
• Avoid beta-blockers within 72 hours of cocaine use due to risk of potentiating coronary vasospasm. 2, 4
• Recognize that combination of cocaine with alcohol or cigarettes intensifies cardiovascular effects. 2
• Treat coexisting psychiatric disorders (depression, anxiety, bipolar disorder) that are common in cocaine users and may complicate management. 2, 4

Monitoring and Disposition

• Hospital admission is often necessary for monitoring of acute cardiovascular and neurological complications. 5
• Serial vital sign assessment is crucial, particularly monitoring for delayed cardiovascular complications. 2, 4
• Most deaths from cocaine intoxication are sudden and occur before medical intervention is possible, emphasizing the importance of aggressive early management. 6