Cocaine Intoxication
Cocaine is the most likely substance ingested in this patient presenting with hypertension, tachycardia, hyperthermia, dilated pupils, diaphoresis, and agitation.
Clinical Reasoning
This patient exhibits a classic sympathomimetic toxidrome that is pathognomonic for cocaine intoxication. The constellation of findings creates a distinctive clinical picture:
Cardiovascular Manifestations
- Hypertension (160/100) and tachycardia (125 bpm) result from cocaine's inhibition of catecholamine reuptake at postsynaptic α- and β-adrenergic receptors 1
- Cocaine causes both tachycardia through β-adrenergic receptor agonism and hypertension through peripheral α-adrenergic receptor agonism 2
- These cardiovascular effects are mediated by both central and peripheral sympathetic mechanisms, with peripheral α-adrenergic vasoconstriction playing a dominant role 3
Autonomic and Neurological Features
- Diaphoresis (sweating) is a hallmark autonomic sign of cocaine toxicity 1
- Dilated pupils (mydriasis) occur from sympathetic stimulation 2, 1
- Agitation and increased psychomotor activity result from CNS stimulation via reuptake blockade of norepinephrine, epinephrine, dopamine, and serotonin 2
Temperature Dysregulation
- Hyperthermia (104°F) is a life-threatening complication of cocaine intoxication that requires rapid external cooling 2, 1
Why Not the Other Substances?
Fentanyl
- Produces the opposite clinical picture: miosis (pinpoint pupils), respiratory depression, bradycardia, and sedation—not mydriasis, tachycardia, or agitation 4
- Fentanyl causes CNS and respiratory depression, not sympathetic hyperactivity 4
GHB (Gamma-Hydroxybutyrate)
- Causes CNS depression with bradycardia, hypothermia, and decreased level of consciousness
- Does not produce sympathomimetic features like hypertension, tachycardia, or mydriasis
Marijuana
- Typically causes mild tachycardia with normal or slightly elevated blood pressure, not severe hypertension 5, 6
- Cannabis does not cause significant hyperthermia, marked diaphoresis, or severe agitation at typical recreational doses 5
- Recent evidence shows no association between cannabis use and incident hypertension 6
- Marijuana produces conjunctival injection (red eyes), not mydriasis
Diagnostic Algorithm
The presence of hypertension + tachycardia + hyperthermia + mydriasis + diaphoresis + agitation strongly indicates cocaine intoxication 1. This combination of findings is virtually pathognomonic and should prompt:
- Immediate recognition of sympathomimetic toxidrome
- Benzodiazepines as first-line treatment for agitation, hypertension, and psychomotor symptoms 2, 7
- Rapid external cooling for life-threatening hyperthermia 2
- Avoidance of pure β-blockers, which can cause paradoxical hypertension through unopposed α-adrenergic stimulation 7, 8
Critical Pitfall
Never use β-blockers alone (such as propranolol) in suspected cocaine toxicity, as this can cause paradoxical severe hypertension through unopposed α-adrenergic vasoconstriction 7, 8. If β-blockade is needed, use combined α/β-blockers like labetalol or carvedilol 7.