Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected/confirmed cocaine toxicity: nonbody packer/stuffer

1st line – observation and monitoring

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INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
1st line – 

observation and monitoring

All patients should be monitored in the emergency department, including cardiac monitoring. Chest pain should prompt obtaining a high-sensitivity cardiac troponin level. 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]​ Patients without significant sequelae are generally safe for discharge when mental status and vital signs have returned to baseline. 

Plus – sedative

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INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
agitation
Plus – 

sedative

Treatment recommended for ALL patients in selected patient group

Benzodiazepines are the drugs of choice for the management of agitation.[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. The principal adverse effect of benzodiazepines is oversedation. This can usually be avoided by judiciously titrating the dose 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.

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Secondary options

haloperidol lactate: 2-10 mg intramuscularly/intravenously every 15 minutes until acute symptoms are controlled, then 2-10 mg every 30 minutes to 6 hours when required, maximum 30 mg/day; 2-10 mg orally every 6 hours when required, maximum 30 mg/day

OR

ziprasidone: 10 mg intramuscularly every 2 hours, or 20 mg intramuscularly every 4 hours, maximum 40 mg/day; switch to oral therapy as soon as possible

Tertiary options

ketamine: consult specialist for guidance on dose

OR

propofol: consult specialist for guidance on dose

Plus – benzodiazepine or antihypertensive therapy

Back
INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
hypertension
Plus – 

benzodiazepine or antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

Benzodiazepines are the drugs of choice for the management of patients with hypertension.[22][34][37]

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] Beta-blockers should be avoided owing to the risk of coronary vasoconstriction and paradoxical hypertension.[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]

Hypertensive catastrophes can be associated with cocaine toxicity.[23]​ See Aortic dissection and Hemorrhagic stroke.

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Plus – benzodiazepine

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INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
seizures
Plus – 

benzodiazepine

Treatment recommended for ALL patients in selected patient group

Benzodiazepines are the drugs of choice for the management of patients with seizures.[22][34]

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Plus – isotonic saline

Back
INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
volume depletion
Plus – 

isotonic saline

Treatment recommended for ALL patients in selected patient group

Correct volume depletion with intravenous isotonic saline.

Plus – external cooling and sedation

Back
INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
hyperthermia, temperature 102.2°F to 105°F (39°C to 40.5°C) without severe agitation
Plus – 

external cooling and sedation

Treatment recommended for ALL patients in selected patient group

Hyperthermia is the most common cause of death associated with cocaine toxicity.

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]

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Plus – external cooling + sedation + paralysis + mechanical ventilation

Back
INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
hyperthermia, temperature >105°F (>40.5°C) with severe agitation
Plus – 

external cooling + sedation + paralysis + mechanical ventilation

Treatment recommended for ALL patients in selected patient group

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]​ 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]​​​

Paralysis should be only performed in conjunction with mechanical ventilation.[46]

Paralysis should be maintained until life-threatening hyperthermia resolves.

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

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

or

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

or

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

-- AND --

vecuronium: consult specialist for guidance on dose

Plus – antiarrhythmic therapy or defibrillation

Back
INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
arrhythmias
Plus – 

antiarrhythmic therapy or defibrillation

Treatment recommended for ALL patients in selected patient group

Cardiac monitoring is indicated in all patients.

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]​​

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]

Primary options

sodium bicarbonate: 1 mEq/kg intravenous infusion

Secondary options

lidocaine: 1 to 1.5 mg intravenous bolus over 2-3 minutes, followed by 1-4 mg/min intravenous infusion for 12-24 hours after rhythm control achieved

Plus – naloxone

Back
INITIAL
|
suspected/confirmed cocaine toxicity: nonbody packer/stuffer
|
coingestion of opioid
Plus – 

naloxone

Treatment recommended for ALL patients in selected patient group

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 titrated to adequate ventilation.[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.

Primary options

naloxone: 0.04 to 2 mg intravenously every 2-3 minutes, maximum 10 mg/total dose

suspected/confirmed cocaine toxicity: body packer/stuffer

1st line – observation and monitoring

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
1st line – 

observation and monitoring

Patients should be observed until they have normal vital signs and mental status, unless there is potential for ongoing absorption of drug, 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 emergency department for 8 hours from the time of suspected ingestion.[26]​ Asymptomatic body stuffers can be monitored for up to 6 hours.[21]

Plus – bowel irrigation + activated charcoal + cardiac monitoring

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
asymptomatic
Plus – 

bowel irrigation + activated charcoal + cardiac monitoring

Treatment recommended for ALL patients in selected patient group

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.[50] Even if body packers are asymptomatic, release of the drugs may be delayed so patients should be observed in emergency department for 8 hours from the time of suspected ingestion.[26]​ Asymptomatic body stuffers can be monitored for up to 6 hours.[21]​​

Primary options

polyethylene glycol/electrolytes: 2 L/hour orally, titrated until clear rectal effluent

and

charcoal, activated: 1 g/kg orally every 2-6 hours when required

Plus – surgical decontamination

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
symptomatic
Plus – 

surgical decontamination

Treatment recommended for ALL patients in selected patient group

If packet rupture occurs (based on symptoms, signs, or positive urine cocaine screen), refer the patient for immediate 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]

Plus – sedative

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
agitation
Plus – 

sedative

Treatment recommended for ALL patients in selected patient group

Benzodiazepines are the drugs of choice for the management of agitation.[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. The principal adverse effect of benzodiazepines is oversedation. This can usually be avoided by judiciously titrating the dose 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 used sometimes but may cause respiratory depression. Propofol should be given only when expertise and facilities are available for mechanical ventilation.

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Secondary options

haloperidol lactate: 2-10 mg intramuscularly/intravenously every 15 minutes until acute symptoms are controlled, then 2-10 mg every 30 minutes to 6 hours when required, maximum 30 mg/day; 2-10 mg orally every 6 hours when required, maximum 30 mg/day

OR

ziprasidone: 10 mg intramuscularly every 2 hours, or 20 mg intramuscularly every 4 hours, maximum 40 mg/day; switch to oral therapy as soon as possible

Tertiary options

ketamine: consult specialist for guidance on dose

OR

propofol: consult specialist for guidance on dose

Plus – benzodiazepine or antihypertensive therapy

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
hypertension
Plus – 

benzodiazepine or antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

Benzodiazepines are the drugs of choice for the management of patients with hypertension.[22][34][37]

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] Beta-blockers should be avoided owing to the risk of coronary vasoconstriction and paradoxical hypertension.[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]

Hypertensive catastrophes can be associated with cocaine toxicity.[23]​ See Aortic dissection and Hemorrhagic stroke.

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Plus – benzodiazepine

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
seizures
Plus – 

benzodiazepine

Treatment recommended for ALL patients in selected patient group

Benzodiazepines are the drugs of choice for the management of patients with seizures.[22][34]

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Plus – isotonic saline

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
volume depletion
Plus – 

isotonic saline

Treatment recommended for ALL patients in selected patient group

Correct volume depletion with intravenous isotonic saline.

Plus – external cooling and sedation

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
hyperthermia, temperature 102.2°F to 105°F (39°C to 40.5°C) without severe agitation
Plus – 

external cooling and sedation

Treatment recommended for ALL patients in selected patient group

Hyperthermia is the most common cause of death associated with cocaine toxicity.

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]

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

OR

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

OR

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

Plus – external cooling + sedation + paralysis + mechanical ventilation

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
hyperthermia, temperature >105°F (>40.5°C) with severe agitation
Plus – 

external cooling + sedation + paralysis + mechanical ventilation

Treatment recommended for ALL patients in selected patient group

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]​ Paralysis is complementary to rapid cooling and should be performed 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.[44] Paralysis should be only performed in conjunction with mechanical ventilation.[43][46]​​​

Paralysis should be maintained until life-threatening hyperthermia resolves.

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

Primary options

diazepam: 5-10 mg intravenously every 3-5 minutes until symptom control achieved

or

midazolam: 1-2 mg intravenously every 3-5 minutes until symptom control achieved

or

lorazepam: 1-2 mg intravenously every 10 minutes until symptom control achieved

-- AND --

vecuronium: consult specialist for guidance on dose

Plus – antiarrhythmic therapy or defibrillation

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
arrhythmias
Plus – 

antiarrhythmic therapy or defibrillation

Treatment recommended for ALL patients in selected patient group

Cardiac monitoring is indicated in all patients.

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]​​

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]

Primary options

sodium bicarbonate: 1 mEq/kg intravenous infusion

Secondary options

lidocaine: 1 to 1.5 mg intravenous bolus over 2-3 minutes, followed by 1-4 mg/min intravenous infusion for 12-24 hours after rhythm control achieved

Plus – naloxone

Back
INITIAL
|
suspected/confirmed cocaine toxicity: body packer/stuffer
|
coingestion of opioid
Plus – 

naloxone

Treatment recommended for ALL patients in selected patient group

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 titrated to adequate ventilation.[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.

Primary options

naloxone: 0.04 to 2 mg intravenously every 2-3 minutes, maximum 10 mg/total dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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