How should an adult with acute cocaine overdose presenting with agitation, hypertension, tachycardia, chest pain, seizures, or hyperthermia be managed?

Treatment of Acute Cocaine Overdose

Benzodiazepines (lorazepam or diazepam) are the first-line treatment for cocaine overdose, addressing agitation, hypertension, tachycardia, and chest pain, while avoiding beta-blockers which cause dangerous unopposed alpha-adrenergic stimulation and paradoxical coronary vasospasm. 1

Immediate Stabilization

Life-Threatening Hyperthermia

• Rapidly cool patients 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
• Aggressive cooling is critical as hyperthermia can rapidly lead to death 1, 2

Cardiovascular Manifestations

• Administer benzodiazepines (lorazepam or diazepam) as first-line treatment for hypertension, tachycardia, chest pain, and agitation 1
• Benzodiazepines control seizures, reduce sympathetic overdrive, and help normalize vital signs 1, 3
• Phentolamine (alpha-adrenergic antagonist) is reasonable for cocaine-induced coronary vasospasm or hypertensive emergencies unresponsive to benzodiazepines 1

Seizure Management

• Treat seizures immediately with diazepam, as seizures are a major determinant of lethality in cocaine poisoning 4
• Control of seizures is of prime importance and can prevent progression to fatal complications 4

Critical Medication Contraindication

• Never administer pure beta-blockers within 72 hours of cocaine use, as they cause unopposed alpha-adrenergic stimulation leading to paradoxical coronary vasospasm 1, 5
• This contraindication applies even to patients with tachycardia or hypertension 1
• Combined beta/alpha-blockers (labetalol, carvedilol) have not shown adverse events in studies but should still be used cautiously 3

Cardiac Complications

Wide-Complex Tachycardia or Cardiac Arrest

• Administer sodium bicarbonate (1-2 mEq/kg IV bolus) to reverse sodium channel blockade in wide-complex tachycardia or cardiac arrest 1
• Correction of acidosis can normalize cardiac rhythm and function in critically ill patients 4
• Lidocaine is reasonable for wide-complex tachycardia, as it competitively binds cocaine at sodium channels and reverses QRS prolongation 1
• Apply standard BLS and ACLS algorithms without modification for cocaine-induced cardiac arrest 1

Acute Coronary Syndrome Protocol

• Obtain immediate 12-lead ECG to identify ST-segment elevation 1
• Use troponin I and T as preferred biomarkers over CK-MB, since CK can be falsely elevated from skeletal muscle activity and rhabdomyolysis 1
• High-risk features requiring monitored admission include: ST-elevation or depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability 1

ST-Elevation MI Management

• Proceed immediately to PCI rather than fibrinolytic therapy, as cocaine users frequently have contraindications to thrombolytics 1
• 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 1

Monitoring and Screening

Essential Assessments

• Screen for life-threatening complications beyond MI: aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy 1
• Serial vital sign assessment is crucial in patients with cardiovascular complications 1
• Monitor for rhabdomyolysis and acute renal failure, which can occur with severe hyperthermia 6

Medication Dosing Considerations

• Carefully dose medications to avoid hypotension after cocaine metabolism, as cocaine's effects are transient (minutes to hours) but treatment effects persist 1
• This is particularly important with vasodilators like nitroglycerin, which may lead to severe hypotension and reflex tachycardia 3

Psychiatric Considerations

• Evaluate and treat coexisting psychiatric disorders (depression, anxiety, bipolar disorder) that are common in cocaine users 1
• Cocaine-induced agitated delirium represents the extreme end of the toxidrome, characterized by severe cardiopulmonary dysfunction, hyperthermia, and acute neurologic changes frequently leading to death 7

Common Pitfalls to Avoid

• Never use beta-blockers in acute cocaine intoxication due to risk of potentiating coronary vasospasm 1, 5
• The combination of cocaine with alcohol or cigarettes intensifies cardiovascular effects 1, 2
• Antipsychotics may worsen consequences by interfering with heat dissipation, causing arrhythmias, and lowering seizure threshold 8
• Suspect cocaine toxicity in younger patients presenting with chest pain or cardiovascular symptoms without traditional risk factors 2