History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors include history of cocaine use, body packing/stuffing, high ambient temperature, male gender, plasma cholinesterase deficiency, age 20 to 30 years, and concomitant use of other sympathomimetics.

tachycardia

Can be mildly or significantly elevated.

hypertension

Can be mildly or significantly elevated. Hypertensive catastrophes can be associated with cocaine toxicity.[26]​ See Aortic dissection and Haemorrhagic stroke.

hyperthermia

If hyperthermia is identified, continuous core-temperature monitoring, usually accomplished with a rectal or oesophageal probe, should be initiated.

agitation

Patients often present in an agitated state.

mydriasis

Mydriasis may be absent when cocaine is taken with a co-ingestant that causes miosis, as it occurs with a 'speedball' of cocaine and heroin.

diaphoresis

Diaphoresis can be most easily appreciated in the axillae. Diaphoresis helps to distinguish sympathomimetic toxidrome from the anticholinergic toxidrome.

Other diagnostic factors

uncommon

seizures

Seizures are generally self-limiting and will respond to benzodiazepine therapy. Status epilepticus is rare following cocaine use.

Risk factors

strong

high ambient temperature

Death from cocaine toxicity correlates with high ambient temperature. This relates to the fact that fatal cocaine toxicity is usually caused by hyperthermia, which can be worsened by higher ambient temperatures.[9]

male sex

The majority of cocaine users are men; therefore, most cocaine toxicity also occurs in men.[7][11][12]

plasma cholinesterase deficiency

Decreased plasma cholinesterase activity is associated with an increased risk of life-threatening cocaine toxicity.[7]​[21]

age 18-25 years

Cocaine use is highest among adults aged 18-25 years.[4]

history of cocaine use

The route and time of any exposure to cocaine may help determine whether symptoms observed are a result of cocaine use. Cocaine has the shortest time to effect when smoked, followed by injection and insufflation. All 3 routes produce peak effect within minutes. Ingestion results in the longest time to effect.

concomitant use of other sympathomimetics

Concomitant use of other sympathomimetics may increase the risk of adverse effects.

weak

poverty

Poverty status of communities correlates with death from cocaine toxicity.[19][20]

cocaine body packing

Rupture of cocaine packets in the body is associated with massive release and systemic absorption of the drug. Even if treatment begins immediately after rupture is identified, there is a low likelihood of treatment success. This contrasts to heroin body packing where packet rupture can be managed with naloxone administration or ventilatory support.

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