Approach

There is no specific antidote for cocaine toxicity. Management is supportive and will depend on which clinical features are present. It is not possible to clinically distinguish cocaine poisoning from other sympathomimetics with certainty. However, because the management of poisoning from these drugs is essentially the same as for cocaine, this is not problematic.

Other illnesses may present with similar features to cocaine toxicity, and if it is not possible to obtain a history because of obtundation or agitation, it may be prudent to empirically treat with antibiotics.

Immediate management

All patients should be monitored in the emergency department (ED) and given supportive care. Ensure adequate ventilation if the patient is unconscious. Volume depletion, cardiac arrhythmias, seizures, hypertension, agitation, and hyperthermia should be managed symptomatically. Chest pain should prompt obtaining a high-sensitivity cardiac troponin (hs-cTn) level. Hs-cTn can be elevated as a result of a variety of ischemic, noncoronary cardiac, and noncardiac causes of cardiomyocyte injury, but cocaine use in itself does not elevate hs-cTn.[23][25]​ If myocardial injury is present or suspected, see Non-ST-elevation myocardial infarction or ST-elevation myocardial infarction. Note that the safety of beta-blockers in life-threatening cocaine-related cardiovascular toxicity is controversial, with studies showing both benefit and harm.[20][33]​​

Benzodiazepines are the drugs of choice for the management of patients with agitation, seizures, tachycardia, and hypertension.[22][34]​ If a patient's condition requires rapid sedation and benzodiazepines are not effective (e.g., extreme hyperthermia or dangerous behavior), an antipsychotic may be given.

Sedation (with a benzodiazepine or an antipsychotic) of an agitated patient may make it easier to perform any necessary investigations and reduces the likelihood of hyperthermia.[20]​ The principal adverse effect of benzodiazepines is oversedation. This can usually be avoided by judiciously titrating dosage to the patient's symptoms. In the most severe cases of oversedation airway protection may be temporarily necessary. Antipsychotics (e.g., haloperidol, ziprasidone) are usually second-line because they may cause ECG changes, anticholinergic effects, or proconvulsant effects.[35]​ Ketamine may be considered if rapid sedation is necessary for patient safety, but the potential for laryngospasm and emergence reactions limit its routine use.[36]​ In practice, propofol is sometimes used but may cause respiratory depression. Propofol should be given only when expertise and facilities are available for mechanical ventilation.

Hypertension usually settles after administration of the benzodiazepine; however, if it persists, specific antihypertensive therapy (e.g., intravenous nitrates or calcium-channel blockers) can be given.[37] Morphine may be helpful if hypertension persists following sedation, especially if pain is a contributor to hypertension.[37] Phentolamine should be considered if there is evidence of vasospasm.[37][38]​ Beta-blockers should be avoided owing to the risk of coronary vasoconstriction and paradoxical hypertension.[37] Hypertensive catastrophes can be associated with cocaine toxicity.[23]​ See Aortic dissection and Hemorrhagic stroke.

Correct volume depletion with intravenous isotonic saline.

Patients should be observed until they have normal vital signs and mental status, unless there is potential for ongoing absorption of drug (body packers or body stuffers), in which case the patients should be observed in a critical care setting until the packets have passed. Even if body packers are asymptomatic, release of the drugs may be delayed so patients should be observed in ED for 8 hours from the time of suspected ingestion.[26]​ Asymptomatic body stuffers can be monitored for up to 6 hours.[21]

Cardiac arrhythmias

Standard advanced life support with the addition of administration of sodium bicarbonate is appropriate for the treatment of life-threatening dysrhythmias caused by cocaine.[20]​ Management options for arrhythmias include:

  • Ventricular fibrillation or nonperfusing (pulseless) ventricular tachycardia requires immediate defibrillation

  • Wide-complex tachycardias are managed with sodium bicarbonate or lidocaine if sodium bicarbonate is ineffective[39][40] 

  • Amiodarone is largely unstudied in cocaine toxicity, and because of its beta-adrenergic antagonism, is not recommended.[41]

If administration of multiple doses of sodium bicarbonate is necessary, care should be taken to avoid hypernatremia or volume overload.

Be aware that lidocaine can be proconvulsant.[42]

Temperature management

Significant hyperthermia should be treated similarly to heat stroke; promptly with sedation and external cooling.[21]​ Cocaine-associated psychomotor agitation with intense physical activity can be approached in a similar way to exertional heat illnesses. The National Athletic Trainers' Association defines a threshold of >105°F (>40.5°C) for increased morbidity and mortality which increase with the length of time body temperature remains above this threshold.[43]​ Ice water immersion produces more rapid cooling than evaporative methods.[44] The clinician should aim to rapidly decrease core temperature with aggressive cooling and should monitor the core temperature continuously.[21]​ 

Paralysis is complementary to rapid cooling and should be considered if there is significant agitation.[22]​ If temperature is >105°F (>40.5°C), external cooling, sedation, and paralysis should be performed regardless of other clinical features.​[43][44]​​​ If paralysis is indicated, vecuronium is an appropriate choice. Succinylcholine is relatively contraindicated in the presence of cocaine because of competition for plasma cholinesterase.[45]

Paralysis should be only performed in conjunction with mechanical ventilation.[46] It should be maintained until life-threatening hyperthermia resolves.

For more information on the treatment of heat stroke, see Heat stroke.

Mixed toxicity

When cocaine is taken in the presence of an opioid (such as a "speedball"), the patient should be treated based on the prevailing toxidrome. For example, if the respiratory rate is decreased and pupils are miotic (elements of the opioid toxidrome), naloxone should be given.[47] If ventilation does not improve following the administration of naloxone, diagnosis of opioid poisoning should be reconsidered. If sympathomimetic symptoms predominate, benzodiazepines may be needed to control agitation and hyperthermia.

Body packing or stuffing

Supportive management of symptoms is the same as for other patients with cocaine toxicity.

If body packers or stuffers show symptoms or signs of cocaine toxicity, they should be immediately referred for surgical decontamination.[26][48]​​ Prompt surgical removal of packets that are no longer sealed, may be life saving.[22]​ Surgical intervention is also indicated for patients with symptoms and signs of bowel obstruction or perforation.[22]

If they are asymptomatic, administer activated charcoal and perform whole-bowel irrigation to decontaminate the patient.[38] Although whole-bowel irrigation has not been rigorously evaluated, it may be helpful when used in the absence of contraindications; it should be considered to facilitate passage of the packets for body packers without evidence of bowel obstruction.[26][27][49]

The body packing patient should be attached to a cardiac monitor until all packets have passed.

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