Tests
1st tests to order
urine toxicology ± gas chromatography/mass spectrometry testing
Test
Particularly indicated in patients with chest pain of unexplained etiology or when there is clinical suspicion of substance use as either a cause or a contributor to an acute coronary syndrome, especially in younger patients (age <50 years).[37]
The results provided by most screening tests are based on the detection of benzoylecgonine, an inactive metabolite with a much longer half-life than cocaine. Benzoylecgonine is used both clinically and forensically to indicate cocaine use given the short half-life of cocaine. Cocaethylene may be detected in the presence of alcohol. If substantial weight is to be placed on the test result (e.g., forensic reasons, child protection), then a confirmatory test using either gas or liquid chromatography/mass spectrometry should be performed.[34]
May reveal presence of additional drugs.
Result
positive for cocaine or metabolites (benzoylecgonine)
ECG
Test
Indicated in patients with chest pain and/or dangerous blood pressure elevation.[35] Patients who have used cocaine may present with chest pain even in the absence of clear cardiac risk factors.
Cocaine-related ECG changes are results of vasoconstrictive effects of cocaine and/or sodium and potassium channel blockade. In some cases, Brugada-pattern ECG findings may be present. Brugada syndrome is a genetic disease predisposing to life-threatening ventricular tachyarrhythmia and sudden cardiac death.[38]
Result
nonspecific T-wave changes or signs of frank infarction with/without rhythm disturbance; or widened QRS/QT prolongation/torsades de pointes; Brugada pattern may be present
Tests to consider
chest x-ray
Test
Indicated for patients presenting with chest pain and/or dyspnea.
Pneumothorax and pneumomediastinum are rare complications of cocaine use, which could be attributed to performing a Valsalva maneuver following insufflation or inhalation, and not a direct effect of the drug itself.
A hemorrhagic alveolitis rarely occurs but is well described in the literature.
Result
atelectasis, pneumothorax, pneumomediastinum, focal consolidation, or diffuse parenchymal ground glass (hemorrhagic alveolitis)
CT head
Test
Indicated for patients demonstrating focal neurologic symptoms.
Result
evidence of ischemic event or bleed associated with focal neurologic signs/symptoms
electroencephalogram
Test
Indicated for patients demonstrating seizure activity, particularly those with recurrent seizures post-cocaine use.
Result
generalized (as opposed to focal) seizure pattern is typical of cocaine-induced seizures
comprehensive blood panel
Test
A comprehensive panel of investigations (i.e., complete blood count, electrolytes, liver and kidney function tests) may be used to evaluate for medical complications of substance use. The cocaine contaminant levamisole has been associated with agranulocytosis.[3][27][33]
Result
decreased WBC count; may be alterations in electrolyte levels, liver and kidney function
hepatitis serology
Test
Testing for viral hepatitis is recommended by the American Society of Addiction Medicine/American Association of Addiction Psychiatrists for all patients with stimulant use disorder, regardless of route of administration of stimulant use, given the higher baseline risk in this group of patients.[27] Testing for viral hepatitis is recommended according to UK guidance for those at risk, including people who inject illicit drugs.[34]
Result
normal or positive in presence of hepatitis B virus or hepatitis C virus infection
HIV serology
Test
Testing for HIV is recommended by the American Society of Addiction Medicine/American Association of Addiction Psychiatrists for all patients with stimulant use disorder, regardless of route of administration of stimulant use, given the higher baseline risk in this group of patients.[27] HIV testing is recommended according to UK guidance for those at risk, including people who inject illicit drugs.[34]
Result
normal or positive in presence of HIV infection
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