What are the symptoms and management of a suspected cocaine overdose in a patient?

Cocaine Overdose: Symptoms and Management

Clinical Presentation

Cocaine overdose manifests as a sympathomimetic toxidrome with cardiovascular, neurological, and systemic complications that can rapidly progress to life-threatening emergencies. 1

Cardiovascular Symptoms

• Tachycardia and hypertension from catecholamine reuptake inhibition causing postsynaptic α- and β-adrenergic receptor stimulation 1
• Chest pain from coronary vasospasm, increased myocardial oxygen demand, and potential thrombosis—the most frequent cocaine-related reason for adult hospitalization 1
• Dysrhythmias including wide-complex tachycardia, QRS prolongation, QT interval prolongation, ventricular tachycardia, and asystolic cardiac arrest from sodium and potassium channel blockade 1
• Acute coronary syndrome can occur even with small intranasal doses, particularly in patients with preexisting coronary disease 1

Neurological Symptoms

• Seizures from CNS stimulation and lowered seizure threshold—a major determinant of lethality 1, 2
• Altered mental status ranging from acute agitation and increased psychomotor activity to paranoid psychosis 1
• Hyperthermia which is rapidly life-threatening and associated with increased mortality 3, 1

Other Manifestations

• Diaphoresis as part of the sympathomimetic toxidrome 1
• Severe metabolic and respiratory acidosis particularly when complicated by seizures 2
• Potential for aortic dissection, coronary artery dissection, myocarditis, cardiomyopathy, rhabdomyolysis, and mesenteric ischemia 4, 3

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Immediate Management Algorithm

Step 1: Resuscitation and Stabilization

Apply standard BLS and ACLS protocols without modification for cardiac arrest, as this approach has demonstrated 55% neurologically intact survival. 3

• Aggressive cooling measures are mandatory for hyperthermia due to its association with increased mortality 3
• Obtain immediate 12-lead ECG to identify ST-segment elevation, which fundamentally changes management strategy 5, 3

Step 2: First-Line Pharmacologic Treatment

Benzodiazepines (lorazepam or diazepam) are the cornerstone of initial management for hypertension, tachycardia, agitation, and seizure control. 3, 5, 2

• Control seizures immediately with diazepam, as seizures are a major determinant of lethality and must be treated as prime importance 2
• Correct acidosis with ventilation and bicarbonate to normalize cardiac rhythm and function 2
• Add sublingual or IV nitroglycerin for chest pain or persistent hypertension 3, 5
• Calcium channel blockers (diltiazem 20 mg IV or verapamil) for persistent cardiovascular instability or coronary vasospasm 3, 5, 6
• Morphine may be added for chest discomfort 3

Step 3: Avoid Beta-Blockers

Never use pure beta-blockers in acute cocaine intoxication due to risk of unopposed alpha-adrenergic stimulation causing coronary vasospasm. 3, 5

• Combined alpha- and beta-blocking agents (like labetalol) may be reasonable only in select circumstances (Class IIb recommendation) 6, 5

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Management Based on ECG Findings

ST-Segment Elevation Present

Administer sublingual nitroglycerin or IV calcium channel blockers immediately (Class I recommendation). 6, 5

• If no response to vasodilators, proceed immediately to coronary angiography if available 6, 5
• PCI is strongly preferred over fibrinolytic therapy because cocaine users frequently have contraindications to thrombolytics (hypertension, seizures, aortic dissection) 6, 5, 3
• 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 6, 5, 3
• Fibrinolytic therapy is acceptable only if ST segments remain elevated despite nitroglycerin and calcium channel blockers, there are no contraindications, and coronary angiography is not possible (Class I recommendation) 6

ST-Segment Depression or T-Wave Changes

• Administer nitroglycerin or oral calcium channel blockers (Class IIa recommendation) 6
• Coronary angiography is probably recommended if unresponsive to nitroglycerin and calcium channel blockers 6
• Aspirin should be administered as part of standard acute coronary syndrome management 5

Normal or Minimal ECG Changes

• Administration of nitroglycerin or oral calcium channel blockers can be beneficial (Class IIa recommendation) 6

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Risk Stratification and Monitoring

High-Risk Features Requiring Monitored Admission

• ST-elevation or depression ≥1 mm 3, 5
• Elevated cardiac markers (troponin I and T preferred over CK-MB, as CK can be elevated from skeletal muscle activity and rhabdomyolysis without myocardial infarction) 3
• Recurrent chest pain 3, 5
• Hemodynamic instability 3, 5
• Approximately 24% develop MI and another 24% develop unstable angina in this high-risk group 5

Low to Intermediate-Risk Patients

• Can be safely managed in a chest pain observation unit for 9-12 hours with clinical and ECG monitoring plus repeat troponin measurements 3
• Only 0.7% to 6% of patients with cocaine-associated chest pain actually have myocardial infarction 3, 6

Screen for Life-Threatening Complications

Beyond MI, actively screen for aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy (Class I recommendation). 3, 5

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Critical Pitfalls to Avoid

• 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 5
• Carefully dose medications to avoid hypotension after cocaine metabolism, as cocaine's effects are transient 3
• The combination of cocaine with alcohol or cigarettes intensifies cardiovascular effects 3, 1
• Prompt consultation with a medical toxicologist is strongly recommended for severe cases 3
• Serial vital sign assessment is crucial in patients with cardiovascular complications 3, 5