eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Cocaine: Differential Diagnoses & Workup

Author: Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Clinical Faculty, Community Medical Centers; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program
Coauthor(s): Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Contributor Information and Disclosures

Updated: Nov 10, 2008

Differential Diagnoses

Angina Pectoris
Status Epilepticus
Cardiomyopathy, Dilated
Syncope
Coma
Toxicity, Amphetamine
Delirium Tremens
Toxicity, Anticholinergic
Delirium, Dementia, and Amnesia
Toxicity, Antidepressant
Epistaxis
Toxicity, Antihistamine
Heat Exhaustion and Heatstroke
Toxicity, Hallucinogen
Hypertensive Emergencies
Toxicity, MDMA
Hypoglycemia
Toxicity, Monoamine Oxidase Inhibitor
Myocardial Infarction
Toxicity, Neuroleptic Agents
Neuroleptic Malignant Syndrome
Toxicity, Phencyclidine
Pediatrics, Status Epilepticus
Toxicity, Selective Serotonin Reuptake Inhibitor
Pediatrics, Tachycardia
Toxicity, Sympathomimetic
Personality Disorders
Toxicity, Thyroid Hormone
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Ventricular Fibrillation
Pneumothorax, Tension and Traumatic
Withdrawal Syndromes
Rhabdomyolysis
Schizophrenia
Shock, Septic

Other Problems to Be Considered

CNS structural considerations (eg, hematoma, tumor, emboli, abscess, contusion)
Drug withdrawal
Exogenous toxins
Hypoxemia
Intracranial hemorrhage
Mania
Seizures
Serotonin syndrome
Thiamine deficiency
Thyroid storm
Thyrotoxicosis
Xanthine toxicity
Water and electrolyte imbalance

Workup

Laboratory Studies

  • No laboratory studies are indicated if the patient has a clear history and mild symptoms.
  • If history is absent or if the patient has moderate-to-severe toxicity, appropriate laboratory tests may be ordered to assess the following:
    • Complete blood cell count (CBC)
    • Electrolytes level
    • Glucose level
    • Pregnancy test
    • Calcium level
    • BUN level
    • Creatinine level
    • Arterial blood gases (ABGs) analysis
    • Creatine kinase (CK) level: An elevated CK level is nonspecific. In 19 patients with elevated CK levels, 5 had documented MI, and 14 had intramuscular injections or other muscle trauma. A CK level may be used to help rule out rhabdomyolysis.
    • Urinalysis (UA)
      • A UA should include inspection to detect myoglobinuria. In cocaine-induced rhabdomyolysis, a dipstick UA reveals an orthotoluidine reaction positive for heme in 75% of patients, findings positive for protein in 67%, and microscopic hematuria in some. On a urine drug screen, Drano or bleach can mask cocaine; alkaline urine may raise this suspicion.
      • Desipramine and amantadine, prescribed to reduce cravings for cocaine, may cause false-positive results on urine tests for amphetamines.
    • Toxicology
      • Urine, blood, gastric contents, and unknown substances found on patients or, such as on mustaches, may be sent for toxicologic evaluation. (Include the patient's clinical history and differential diagnosis of the toxins in question to guide the laboratory evaluations). However, high plasma cocaine concentrations are rarely observed because cocaine has a short half-life of 30-45 minutes. Furthermore, numerous studies have demonstrated that toxicology screens rarely change the clinical treatment of patients.
      • Although concentrations higher than 1 mg/L are generally associated with toxicity, deaths have been reported with blood levels of 0.1-20.9 mg/L. Because of this wide range of toxicity, quantitative blood levels of cocaine or metabolites are generally not clinically useful.
    • Half-life
      • Cocaine exhibits first-order kinetics over a wide dose range; therefore, after 5 half-lives (approximately 4 h), virtually all of the cocaine should have been converted to its metabolites. Hollander et al concur, indicating that urinary cocaine may be detected for 4-8 hours after a single intranasal dose. However, Lewin, Goldfrank, and Weisman maintain that most cocaine is excreted in the urine within 24 hours of ingestion.22
      • Benzoylecgonine may be present in urine for as long as 60 hours after single use and for as long as 22 days after the cessation of heavy cocaine use. If the ratio of benzoylecgonine to cocaine found in the urine is less than 100:1, either the cocaine was ingested less than 10 hours before collection of the sample or ongoing liberation of cocaine is occurring from a body package.
  • Also consider tests of the following:
    • Cardiac markers in patients with chest pain
    • Lactate dehydrogenase (LDH) level, aspartate aminotransferase (AST, formerly serum glutamic-oxaloacetic transaminase [SGOT]) level, prothrombin time (PT), activated partial thromboplastin time (aPTT), CSF, and cultures of blood and urine in patients with elevated temperatures
    • Serum osmolality and ketones in patients with altered mental status

Imaging Studies

  • General chest radiography
    • Obtain a chest radiograph in patients with chest pain, hypoxia, or moderate-to-severe toxicity. The chest image of drug users may reveal diffuse granulomatous changes resulting from chronic parenteral abuse due to the injection of inert insoluble ingredients of oral preparations or insolubles used to cut cocaine (eg, talc). Septic pulmonary emboli appear round or wedge shaped; they may clear rapidly or cavitate. Aspiration pneumonitis and noncardiogenic pulmonary edema also may be demonstrated. Pulmonary abscesses may become evident after aspiration pneumonitis or after an intravenous injection of bacteria or toxic organic or inorganic materials.
    • Chest images may occasionally reveal a needle, catheter, or fragment thereof, which was lost during drug injection. An aneurysm or pseudoaneurysm may be noted if the person was mainlining, or directly injecting, into a central artery or vein; this finding is an indication for further imaging studies. Up to 50% of posteroanterior (PA) chest images may demonstrate normal findings, with pneumomediastinum demonstrable only on lateral views.
    • To evaluate an inflamed area (abscess or cellulitis) or nonhealing wound in an intravenous drug user, include a radiograph, and look for foreign bodies, such as needles or parts thereof, metal, glass, or painted materials, that may have become imbedded after trauma. A radiograph of the infected area also may reveal subcutaneous emphysema produced by gas-forming organisms in an anaerobic infection.
    • Skeletal images may reveal osteomyelitis or fractures. However, osteomyelitis may not be demonstrable on plain images for 1-2 weeks, and other imaging studies should be performed if such a diagnosis is considered. Fractures are a concern because people under the influence of a drug may have injury that they do not recognize because of their intoxication.
  • Chest radiography to investigate body packing
    • Swallowed packets of cocaine may rupture, resulting in acute cocaine poisoning. They may also critically obstruct the esophagus or small bowel, typically at the ileocecal valve. The drug packets typically weigh 1-12 g.
    • Begin with plain images of the abdomen to search for packages. However, the rate of false-negative results is 1.2-33%, which may be because drug packages may not produce a radiographically visible outline or because shadows caused by constipation may obscure the silhouette.
    • Results from ultrasonography are commonly disappointing.
    • Contrast-enhanced study of the bowel or abdominal CT may be the only way of identifying the packages.
    • Regular radiologic examination is imperative to confirm successful transit of packages through the GI tract.
    • McCarron and Wood reported a series of 75 patients with suspected body packing of cocaine who were evaluated with kidneys, ureters, and bladder (KUB) radiography. Cocaine packages (15-175 per individual) were retrieved from 48 patients. In 73%, the KUB images showed foreign bodies. KUB findings were negative in 3% of patients with cocaine packages in the rectum and in another 16% who subsequently passed 15-135 packages.23
    • McCarron and Wood identified 3 types of packages, with the following physical and radiographic characteristics and risk for rupture23 :
      • Type 1: Condoms, toy balloons, or fingers of latex gloves contained cocaine in loose white powder form. Typically, the package material was stuffed with cocaine, tied, folded back on itself, and tied again at the opposite end. A variation involved wrapping a package with masking tape to make a small bundle, then covering it with 2 more condoms tied with fishing line. Type 1 packages radiographically appeared as well-defined circular or cigar-shaped white opacities. Ties, if radiographically apparent, had a rosette appearance. If gas halos were observed, they were irregular. This type of cocaine package posed the highest risk for breakage or leaching.
      • Type 2: About 5-7 layers of tubular latex, with a smooth tie on each end, covered white or light yellow matted cocaine powder. On direct inspection of the bundles, they appeared light yellow and were relatively large and uniform in size. These radiopaque bundles were oblong. When viewed radiographically, gas halos were present and regular, but no ties were apparent. Type 2 packages were less susceptible to breaking than type 1 packages.
      • Type 3: Yellow, hardened cocaine paste wrapped in aluminum foil, then wrapped again with 3-5 layers of tubular latex and securely tied at both ends. These packages were hard, smaller than type 1 and type 2 packages, and irregularly sized. They did not appear as foreign bodies on abdominal images. No breakage or leaching of cocaine was reported with this type of package.
    • The risk of bag rupture or leaching increases if the bag remains in the GI tract for a long period. In one series, 2 patients had sloughed pieces of wrapping, and 1 had evidence of leaching. After the container believed to be the last has passed, Perrone and Hoffman recommend imaging (eg, Gastrografin upper-GI series with small-bowel follow through) to ensure that the GI system has been fully purged of all packets.24
  • The ACEP recommends brain CT in patients presenting with first-time seizures. Perrone and Hoffman recommend CT scans of the head in all patients with cocaine-associated seizures because intracranial pathology often causes the seizures.24

Other Tests

  • Obtain a 12-lead ECG in patients with chest pain; hypoxia; dyspnea; an irregular, rapid, or slow pulse; altered mental status; or moderate-to-severe toxicity.
    • Of 48 patients admitted to an ICU with cocaine-induced chest pain, 86% had abnormal ECG findings, but only 6% were found to have sustained a MI.
    • The Brugada sign has been noted in cocaine users. This finding should prompt consideration of its implications for sudden cardiac death.
  • Coma has several possible etiologies in the cocaine-toxic patient, including the second (nonconvulsive) stage of status epilepticus. Therefore, immediate STAT EEG is indicated in patients presenting with unexplained coma in whom this is thought to be a possibility.

Procedures

  • Renzi recommends lumbar puncture (LP) to rule out intracranial hemorrhage in patients with persistent headache after the patient's BP is normalized and contraindications are ruled out on head CT.25
    • When LP is considered for this possible indication, remember that headaches are common in cocaine users secondary to decreased uptake of serotonin.
    • Consider LP in all patients with hyperthermia or altered mental status.

More on Toxicity, Cocaine

Overview: Toxicity, Cocaine
Differential Diagnoses & Workup: Toxicity, Cocaine
Treatment & Medication: Toxicity, Cocaine
Follow-up: Toxicity, Cocaine
References
[ CLOSE WINDOW ]

References

  1. Gold MS. Cocaine (and crack): clinical aspects. In: Lowinson JH, et al, eds. Substance Abuse: A Comprehensive Text. 2nd ed. Lippincott Williams & Wilkins: Baltimore, Md; 1992.

  2. Rose JS. Cocaethylene: a current understanding of the active metabolite of cocaine and ethanol. Am J Emerg Med. Jul 1994;12(4):489-90. [Medline].

  3. Signs SA, Dickey-White HI, Vanek VW, et al. The formation of cocaethylene and clinical presentation of ED patients testing positive for the use of cocaine and ethanol. Am J Emerg Med. Nov 1996;14(7):665-70. [Medline].

  4. Karch SB. Cardiac arrest in cocaine users. Am J Emerg Med. Jan 1996;14(1):79-81. [Medline].

  5. Darke S, Kaye S, Duflou J. Comparative cardiac pathology among deaths due to cocaine toxicity, opioid toxicity and non-drug-related causes. Addiction. Dec 2006;101(12):1771-7. [Medline].

  6. Qureshi AI, Suri MF, Guterman LR, et al. Cocaine use and the likelihood of nonfatal myocardial infarction and stroke: data from the Third National Health and Nutrition Examination Survey. Circulation. Jan 30 2001;103(4):502-6. [Medline].

  7. Hollander JE, Hoffman RS, Gennis P, et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med. Jul-Aug 1994;1(4):330-9. [Medline].

  8. Jouriles NJ. Pericardial and myocardial disease. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 5th ed. St Louis, Mo: Mosby; 2002.

  9. Ruttenber AJ, Lawler-Heavner J, Yin M, et al. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J Forensic Sci. Jan 1997;42(1):25-31. [Medline].

  10. Callaway CW, Clark RF. Hyperthermia in psychostimulant overdose. Ann Emerg Med. Jul 1994;24(1):68-76. [Medline].

  11. 2006 National Survey on Drug Use and Health. SAMHSA; 2006. [Full Text].

  12. Drug Abuse Warning Network, 2005:National Estimates of Drug-RelatedEmergency Department Visits. SAMHSA; 2006. 23.

  13. Drug Abuse Warning Network, 2003. Area Profiles of Drug-Related Mortality. Available at: http://dawninfo.samhsa.gov/files/ME_report_2003_Front.pdf. [Full Text].

  14. Hollander JE, Todd KH, Green G, et al. Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med. Dec 1995;26(6):671-6. [Medline].

  15. California. Turner died of overdose. The New York Times. January 17, 2008;p A23.

  16. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2004: National Estimates of Drug-Related Emergency Department Visits. Available at http://dawninfo.samhsa.gov/files/DAWN2k4ED.htm#Dred2.

  17. Hollander JE, Hoffman RS. Cocaine-induced myocardial infarction: an analysis and review of the literature. J Emerg Med. Mar-Apr 1992;10(2):169-77. [Medline].

  18. Shanti CM, Lucas CE. Cocaine and the critical care challenge. Crit Care Med. Jun 2003;31(6):1851-9. [Medline].

  19. Hoffman RS, Reimer BI. "Crack" cocaine-induced bilateral amblyopia. Am J Emerg Med. Jan 1993;11(1):35-7. [Medline].

  20. Ball SA, Carroll KM, Babor TF, et al. Subtypes of cocaine abusers: support for a type A-type B distinction. J Consult Clin Psychol. Feb 1995;63(1):115-24. [Medline].

  21. Rivara FP, Mueller BA, Somes G, et al. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA. Aug 20 1997;278(7):569-75. [Medline].

  22. Lewin NA, Goldfrank LR, Weisman RS. Cocaine. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 3rd ed. Appleton Century Crofts: Norwalk, Conn; 1986.

  23. McCarron MM, Wood JD. The cocaine 'body packer' syndrome. Diagnosis and treatment. JAMA. Sep 16 1983;250(11):1417-20. [Medline].

  24. Perrone J, Hoffman RS. Cocaine. In: Tintinalli JE, ed. Emergency Medicine: A Comprehensive Study Guide. 4th ed. NY: McGraw-Hill; 1996.

  25. Renzi FP. Cocaine poisoning. In: Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lippincott Raven Publishers; 1996.

  26. DiMaio TG, DiMaio VJM. Excited Delirium Syndrome: Cause of Death and Prevention. New York: CRC Taylor and Francis Group; 2006.

  27. American Heart Association. Toxicology in Emergency Cardiovascular Care. In: Field JM. Advanced Cardiovascular Life Support Resource Text for Instructors and Experienced Providers. 2008:259-287.

  28. McIntyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med. Jan 8 2004;350(2):179-81. [Medline].

  29. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. Jan 8 2004;350(2):105-13. [Medline].

  30. Derlet RW, Tseng CC, Albertson TE. Cocaine toxicity and the calcium channel blockers nifedipine and nimodipine in rats. J Emerg Med. Jan-Feb 1994;12(1):1-4. [Medline].

  31. Derlet RW. More on lidocaine use in cocaine toxicity. J Emerg Nurs. Aug 1998;24(4):303. [Medline].

  32. Malbrain ML, Neels H, Vissers K, et al. A massive, near-fatal cocaine intoxication in a body-stuffer. Case report and review of the literature. Acta Clin Belg. 1994;49(1):12-8. [Medline].

  33. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Toxicology in ECC. Circulation. 2005;112:IV-126-IV-132.

  34. Committee on Child Abuse and Neglect. Distinguishing sudden infant death syndrome from child abuse fatalities. Committee on Child Abuse and Neglect. American Academy of Pediatrics. Pediatrics. Jul 1994;94(1):124-6. [Medline].

  35. Aufderheide TP, Gibler WB. Acute ischemic coronary syndrome. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St Louis, Mo: Mosby; 1998.

  36. Kercher EE. Anxiety disorders. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St Louis, Mo: Mosby; 1998.

  37. Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS. Nonseasonal heatstroke. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 3rd ed. Appleton Century Crofts: Norwalk, Conn; 1986.

  38. Colucciello SA, Tomaszewski C. Substance abuse. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St Louis, Mo: Mosby; 1998.

  39. Marzuk PM, Tardiff K, Leon AC, et al. Fatal injuries after cocaine use as a leading cause of death among young adults in New York City. N Engl J Med. Jun 29 1995;332(26):1753-7. [Medline].

  40. Brookoff D, O'Brien KK, Cook CS, et al. Characteristics of participants in domestic violence. Assessment at the scene of domestic assault. JAMA. May 7 1997;277(17):1369-73. [Medline].

  41. Ostrea EM Jr, Ostrea AR, Simpson PM. Mortality within the first 2 years in infants exposed to cocaine, opiate, or cannabinoid during gestation. Pediatrics. Jul 1997;100(1):79-83. [Medline].

  42. Reece RM. Fatal child abuse and sudden infant death syndrome: a critical diagnostic decision. Pediatrics. Feb 1993;91(2):423-9. [Medline].

  43. 2006 National Survey on Drug Abuse and Health: National Results. SAMHSA; 2007.

  44. ACEP Clinical Policies Committee; Clinical Policies Subcommittee on Seizures. Clinical Policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. May 2004;43(5):605-25. [Medline].

  45. Toxicology in Emergency Cardiovascular Care. In: Cummins RO, Fields JM, & Hazinski MF. ACLS for Experienced Providers. Dallas TX: American Heart Association; 2003:Chapter 3.

  46. Albertson TE, Derlet RW, Van Hoozen BE. Methamphetamine and the expanding complications of amphetamines. West J Med. Apr 1999;170(4):214-9. [Medline].

  47. American Heart Association in Collaboration with ILCOR. Toxicology in ECC. In: Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. American Heart Association. 2000;I-223-I-228.

  48. Bailey DN. Cocaethylene: a novel cocaine homolog. West J Med. Jul 1997;167(1):38-9. [Medline].

  49. Bandi V. Recognizing drug-induced hyperthermia syndrome: how to distinguish between the possible toxicities. J Crit Illn. Dec 2002.

  50. Billman GE. The effect of adrenergic receptor antagonists on cocaine-induced ventricular fibrillation: alpha but not beta adrenergic receptor antagonists prevent malignant arrhythmias independent of heart rate. J Pharmacol Exp Ther. Apr 1994;269(1):409-16. [Medline].

  51. Bontempo LJ. Rhabdomyolysis. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 5th ed. St Louis, Mo: Mosby; 2002.

  52. Brady WJ, Ferguson JD, Ullman EA, et al. Myocarditis: emergency department recognition and management. Emerg Med Clin North Am. Nov 2004;22(4):865-85. [Medline].

  53. Brookoff D, Rotondo MF, Shaw LM, et al. Coacaethylene levels in patients who test positive for cocaine. Ann Emerg Med. Mar 1996;27(3):316-20. [Medline].

  54. Bruce CJ, Livingston DH, Schneider CA, et al. The effect of cocaine on the physiologic response to hemorrhagic shock. Surgery. Aug 1993;114(2):429-34; discussion 434-5. [Medline].

  55. Calder KK, Severyn FA. Surgical emergencies in the intravenous drug user. Emerg Med Clin North Am. Nov 2003;21(4):1089-116. [Medline].

  56. Camus P, Bonniaud P, Fanton A, et al. Drug-induced and iatrogenic infiltrative lung disease. Clin Chest Med. Sep 2004;25(3):479-519, vi. [Medline].

  57. Cobaugh DJ, Schneider SM, Benitez JG, et al. Cocaine balloon aspiration: successful removal with bronchoscopy. Am J Emerg Med. Sep 1997;15(5):544-6. [Medline].

  58. Coluciello SA, Hockburger RS. Suicide. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby: St Louis, Mo; 1998.

  59. Cregler LL, Mark H. Medical complications of cocaine abuse. N Engl J Med. Dec 4 1986;315(23):1495-500. [Medline].

  60. Cummins RO, ed. Toxicology in emergency cardiovascular care. In: ACLS for Experienced Providers. American Heart Association; 2003.

  61. Edell DS, McSwain M. Cocaine poisoning: an easily missed diagnosis in an infant. Clin Pediatr (Phila). Dec 1993;32(12):746-7. [Medline].

  62. Falk JL, O'Brien JF, Shesser R. Heart Failure. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, MO: Mosby; 2002.

  63. Feldman JA, Fish SS, Beshansky JR, et al. Acute cardiac ischemia in patients with cocaine-associated complaints: results of a multicenter trial. Ann Emerg Med. Nov 2000;36(5):469-76. [Medline].

  64. Field JM, Hazinski MF, Gilmore D, eds. Handbook of Emergency Cardiovascular Care for Healthcare Providers. American Heart Association; 2005.

  65. Fines RE, Brady WJ, DeBehnke DJ. Cocaine-associated dystonic reaction. Am J Emerg Med. Sep 1997;15(5):513-5. [Medline].

  66. Gallagher EJ. Neurologic principles. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. New York: McGraw-Hill; 2002.

  67. Gatof D, Albert RK. Bilateral thumb burns leading to the diagnosis of crack lung. Chest. Jan 2002;121(1):289-91. [Medline].

  68. Gold MS, Miller MS, Jonas JM. Cocaine (and crack): neurobiology. In: Lowinson JH, Ruiz P, Millman RB, eds. Substance Abuse: A Comprehensive Text. 2nd ed. Lippincott Williams & Wilkins: Baltimore, Md; 1992.

  69. Goldfrank LR. Toxicologic radiology. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 3rd ed. Appleton Century Crofts: Norwalk, Conn; 1986.

  70. Goldfrank LR, Flomenbaum NE, Lewin NA, et al. Principles of managing the poisoned or overdosed patient: An overview. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. 2002.

  71. Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS. Withdrawal. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 3rd ed. Appleton Century Crofts: Norwalk, Conn; 1986.

  72. Gumpeni R. Finding the cause of wheezing. (Diagnostic puzzlers: challenging cases to test your clinical skills). Journal of Respiratory Diseases;. July 1, 2003.

  73. Hamid H, El-Mallakh RS, Vandeveir K. Substance abuse: medical and slang terminology. South Med J. Mar 2005;98(3):350-62. [Medline].

  74. Heilig S, Rodriguez M, Martin S, Louie D, eds. Domestic violence: A practical approach for clinicians. San Francisco Medical Society:Available at: http://www.sfms.org/domestic.html. [Full Text].

  75. Hoffman RS. Respiratory principles. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. New York: McGraw-Hill; 2002.

  76. Hollander JE, Hoffman RS. Cocaine. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. 2002.

  77. Jones JS, Dickson K, Carlson S. Unrecognized pregnancy in the overdosed or poisoned patient. Am J Emerg Med. Sep 1997;15(5):538-41. [Medline].

  78. Karch SB. Karch's Pathology of Drug Abuse. In: Cocaine. 3rd ed. Boca Raton FL: CRC Press; 2002.

  79. Katz AA, Hoffman RS, Silverman RA. Phenytoin toxicity from smoking crack cocaine adulterated with phenytoin. Ann Emerg Med. Sep 1993;22(9):1485-7. [Medline].

  80. Keller KB, Lemberg L. The cocaine-abused heart. Am J Crit Care. Nov 2003;12(6):562-6. [Medline].

  81. Kleerup EC, Koyal SN, Marques-Magallanes JA, et al. Chronic and acute effects of "crack" cocaine on diffusing capacity, membrane diffusion, and pulmonary capillary blood volume in the lung. Chest. Aug 2002;122(2):629-38. [Medline].

  82. Kothari R, Barsan WG. Stroke. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 5th ed. St Louis, Mo: Mosby; 2002.

  83. Kulig K. General management principles. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby: St Louis, Mo; 1998.

  84. Leikin JB, Heyn-Lamb R, Aks S, et al. The toxic patient as a potential organ donor. Am J Emerg Med. Mar 1994;12(2):151-4. [Medline].

  85. Littmann L, Monroe MH, Kerns WP 2nd, et al. Brugada syndrome and "Brugada sign": clinical spectrum with a guide for the clinician. Am Heart J. May 2003;145(5):768-78. [Medline].

  86. Lukas SE, Sholar M, Lundahl LH, et al. Sex differences in plasma cocaine levels and subjective effects after acute cocaine administration in human volunteers. Psychopharmacology (Berl). Jun 1996;125(4):346-54. [Medline].

  87. Marik PE, Varon J. The management of status epilepticus. Chest. Aug 2004;126(2):582-91. [Medline].

  88. McKay CA. Can the Laboratory Help Me? Toxicology Laboratory Testing in the Possibly Poisoned Pediatric Patient. CPEM. Jun 2005;6(2):116-122.

  89. McMullen MJ. Cocaine, amphetamines, and other stimulants. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby: St Louis, Mo; 1998.

  90. Meraputi. Chronology of diseases and death from illicit recreational drug use in the US. Available at: http://www.meraputi.com.

  91. Miller MB. Arrhythmias associated with drug toxicity. Emerg Med Clin North Am. May 1998;16(2):405-17. [Medline].

  92. Minor RL Jr, Scott BD, Brown DD, et al. Cocaine-induced myocardial infarction in patients with normal coronary arteries. Ann Intern Med. Nov 15 1991;115(10):797-806. [Medline].

  93. Mokhlesi B, Corbridge T. Toxicology in the critically ill patient. Clin Chest Med. Dec 2003;24(4):689-711. [Medline].

  94. Mokhlesi B, Leiken JB, Murray P, et al. Adult toxicology in critical care: part I: general approach to the intoxicated patient. Chest. Feb 2003;123(2):577-92. [Medline].

  95. Mokhlesi B, Leikin JB, Murray P, et al. Adult toxicology in critical care: Part II: specific poisonings. Chest. Mar 2003;123(3):897-922. [Medline].

  96. Mone SM, Gillman MW, Miller TL, et al. Effects of environmental exposures on the cardiovascular system: prenatal period through adolescence. Pediatrics. Apr 2004;113(4 Suppl):1058-69. [Medline].

  97. National Institute on Drug Abuse. Current trends in drug use worldwide. NIDA Notes. 1998;Vol 13:9.

  98. National Institute on Drug Abuse. NIDA InfoFacts: Crack and Cocaine. Available at: http://www.nida.nih.gov/Infofacts/cocaine.html. 2005;[Full Text].

  99. National Institute on Drug Abuse. NIDA InfoFacts: Crack and Cocaine. Available at: http://www.nida.nih.gov/Infofacts/cocaine.html. Revised 3/05. [Full Text].

  100. National Institute on Drug Abuse. NIDA InfoFacts: Hospital Visits. Available at: http://www.drugabuse.gov/infofacts/HospitalVisits.html. 2005;[Full Text].

  101. National Institute on Drug Abuse. NIDA InfoFacts: Hospital Visits. Available at: http://www.drugabuse.gov/infofacts/HospitalVisits.html. [Full Text].

  102. National Institute on Drug Abuse. Research Report Series - Cocaine Abuse and Addiction. Available at: http://www.nida.nih.gov/ResearchReports/Cocaine/cocaine2.html#scope. 2005;[Full Text].

  103. National Institute on Drug Abuse. Research Report Series - Cocaine Abuse and Addiction. What is cocaine? Available at: http://www.nida.nih.gov/ResearchReports/Cocaine/cocaine2.html#scope. [Full Text].

  104. O'Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol. Dec 1993;14(4):289-95. [Medline].

  105. Office of Applied Statistics, SAMHSA. Cocaine abuse. Available at: http://www.health.org/govpubs/rpo926/#Coca. [Full Text].

  106. Office of Applied Statistics, SAMHSA. Drug Abuse Warning Network (DAWN) Annual Medical Examiner Data 1999. Available at: http://www.samhsa.gov/oas/dawn.htm#MEcomp. [Full Text].

  107. Office of Applied Statistics, SAMHSA. Drug Abuse Warning Network (DAWN) Detailed Emergency Department Tables 1999. Available at: http://www.samhsa.gov/oas/dawn.htm. [Full Text].

  108. Office of Applied Statistics, SAMHSA. Drug-Related Emergency Room Cases Decline Nationally. 1997;Available at: http://www.samhsa.gov/press/97/971230o.htm. [Full Text].

  109. Office of Applied Studies, SAMHSA. Summary of Findings from the 1998 National Household Survey on Drug Abuse. Available at: http://www.samhsa.gov/oas/nhsda/98SummHtml/TOC.htm. [Full Text].

  110. Office of National Drug Control Policy, ONDCP. Drug Policy Information Clearinghouse Factsheet. Cocaine November 2003. Available at: http://www.whitehousedrugpolicy.gov/publications/factsht/cocaine/. [Full Text].

  111. Perron AD, Gibbs M. Thoracic aortic dissection secondary to crack cocaine ingestion. Am J Emerg Med. Sep 1997;15(5):507-9. [Medline].

  112. Pollack CV, Pollack ES. Seizures. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 5th ed. St Louis, Mo: Mosby; 2002.

  113. Pulse Check National Trends in Drug Abuse. Trends in drug use: Spring-Fall. In: Part II: Cocaine. 1996:Available at: http://ncjrs.org/pctrend2.html. [Full Text].

  114. Ramrakha PS, Barton I. Drug smuggler's delirium. BMJ. Feb 20 1993;306(6876):470-1. [Medline].

  115. Review of Optometry. Talc retinopathy. (Vitreous and retina). March 15, 2005.

  116. Saguil A. Evaluation of the patient with muscle weakness. Am Fam Physician. Apr 1 2005;71(7):1327-36. [Medline].

  117. Sauter D, Habal R. Drug therapy and substance abuse. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby: St Louis, Mo; 2002.

  118. Savitt DL, Roberts JR, Merigian KS. Psychoactive drug abuse. In: Rosen P, ed. Emergency Medicine Concepts and Clinical Practice. 3rd ed. St Louis, Mo: Mosby; 1992.

  119. Schwartz DT. Diagnostic imaging in toxicology. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. 2002.

  120. Seymour A. Drug smuggler's delirium. BMJ. Apr 10 1993;306(6883):1002. [Medline].

  121. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2003. Interim National Estimates of Drug-Related Emergency Department Visits. DAWN Series D-26, DHHS Publication No. (SMA) 04-3972. Rockville, MD, 2004. Available at: http://dawninfo.samhsa.gov/files/DAWN_ED_Interim2003.pdf. [Full Text].

  122. Sudhakar CB, Al-Hakeem M, MacArthur JD, et al. Mesenteric ischemia secondary to cocaine abuse: case reports and literature review. Am J Gastroenterol. Jun 1997;92(6):1053-4. [Medline].

  123. Tazelaar HD, Karch SB, Stephens BG, et al. Cocaine and the heart. Hum Pathol. Feb 1987;18(2):195-9. [Medline].

  124. Ungar JR, Schwartz GR, Levine DG. Drug and substance abuse emergencies. In: Schwartz GR, ed. Principles and Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lea & Febiger; 1992.

  125. Van Mieghem C, Sabbe M, Knockaert D. The clinical value of the ECG in noncardiac conditions. Chest. Apr 2004;125(4):1561-76. [Medline].

  126. Vassallo SU, Delaney KA. Thermoregulatory principles. In: Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. 2002.

  127. Volkow ND, Wang GJ, Fowler JS, et al. Enhanced sensitivity to benzodiazepines in active cocaine-abusing subjects: a PET study. Am J Psychiatry. Feb 1998;155(2):200-6. [Medline].

  128. Wang RY. pH-dependent cocaine-induced cardiotoxicity. Am J Emerg Med. Jul 1999;17(4):364-9. [Medline].

  129. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline].

  130. Weiner AL, Bayer MJ, McKay CA Jr, et al. Anticholinergic poisoning with adulterated intranasal cocaine. Am J Emerg Med. Sep 1998;16(5):517-20. [Medline].

  131. Wilson LD. Rapid progression of coronary artery disease in the setting of chronic cocaine abuse. J Emerg Med. Jul-Aug 1998;16(4):631-4. [Medline].

  132. Winbery S, Blaho K, Logan B, et al. Multiple cocaine-induced seizures and corresponding cocaine and metabolite concentrations. Am J Emerg Med. Sep 1998;16(5):529-33. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

cocaine toxicity, cocaine ingestion, cocaine poisoning, benzoylmethylecgonine, blow, coke, crack, snow, toot, nose candy, freebase, club drug, rock, Erythroxylon coca, ecgonine, norcocaine, ethylbenzoylecgonine, cocaethylene, cocaine-induced myocardial infarction, cocaine-induced MI, speedball, ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage, hyperthermia, agitated delirium, excited delirium, acute coronary syndromes, cocaine-associated rhabdomyolysis, hyperthermia, ventricular dysrhythmias, myocarditis, microfocal fibrosis, contraction band necrosis, tachydysrhythmias, cardiac arrest, coronary atherosclerosis, dilated cardiomyopathy, cocaine-induced seizures, cocaine-associated seizures, neuroleptic malignant syndrome, NMS, dystonic reactions, bradykinesia, akinesia, akathisia, pseudoparkinsonism, catalepsy, neuroleptic-induced dystonias, sudden death, psychostimulant-induced hyperthermia, myoglobinuria, acute tubular necrosis, acidemia, aortic dissection, pneumothorax, pneumopericardium, pneumomediastinum, pulmonary hemorrhage, pulmonary infarction, diffuse alveolar hemorrhage, neurogenic pulmonary edema, exacerbation of asthma, eosinophilic lung disease, chronic diffuse interstitial pneumonia, sudden infant death syndrome, SIDS, pulmonary hypertension, transient pulmonary infiltrates, crack lung, nasal septum perforation, bronchiolitis obliterans organizing pneumonia, granulomatosis, sinusitis, epiglottitis, bronchitis, cellulose granulomas in lung, panlobular emphysema, alveolar accumulation of carbonaceous material, airway burns, tracheal stenosis, hypersensitivity pneumonitis, toxic encephalopathy, neurogenic syncope, movement disorders, cocaine-induced hypertension, crack dancing, mesenteric ischemia, renal infarction, cocaine-associated cerebral vasculitis, central retinal artery occlusion, blurring of vision, endophthalmitis, optic neuropathy, corneal ulcerations, hallucinations, anxiety, depression, delirium, paranoia, toxic psychosis, cocaine bingeing, pocket shot, necrotizing angiitis, acquired immunodeficiency syndrome, AIDS, thrombophlebitis, cellulitis, talc-induced hepatitis, subacute bacterial endocarditis, SBE, foreign-particle pulmonary emboli, tetanus, cotton fever, malaria

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Clinical Faculty, Community Medical Centers; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program
Lynn Barkley Burnett, EdD, MS, LLB(c) is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Association for the Advancement of Science, American Association of Suicidology, American Cancer Society, American College of Sports Medicine, American Heart Association, American Professional Society on the Abuse of Children, American Public Health Association, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, American Stroke Association, Association of Military Surgeons of the US, Christian Medical & Dental Society, European Society for Trauma and Emergency Surgery, European Society of Cardiology, European Society of Intensive Care Medicine, European Society of Paediatric and Neonatal Intensive Care, Faculty of Forensic and Legal Medicine of the Royal College of Physicians of London, International Homicide Investigators Association, New York Academy of Sciences, Royal College of Surgeons of Edinburgh, Royal Society of Medicine, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and World Association for Disaster and Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

Medical Editor

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio
Miguel C Fernandez, MD, FAAEM, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.