eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Cocaine: Follow-up

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

Follow-up

Further Inpatient Care

  • Patients with chest pain should be admitted if their pain is severe, sustained, recurrent, associated with significant cardiac risk factors, or associated with any acute cardiopulmonary symptoms accompanied by positive cardiac markers or ECG changes suggestive of ischemia.
  • Other indications for admission to a critical care unit may include patients with unresolved moderate-to-severe signs and symptoms, including seizures and focal neurologic deficits and those with suspected ingestion of packages of cocaine.

Further Outpatient Care

  • Refer the patient for drug abuse counseling and treatment.
  • If domestic violence is identified from the history or physical examination, refer the patient to an appropriate agency that makes referrals for physical and psychological problems and provides safety, treatment, advocacy, and support.
  • Provide referral for counseling or testing for HIV and other sexually transmitted disease (STD), as appropriate.

Transfer

  • If critical care is not available, transfer patients requiring such care to an appropriate facility, preferably in an advanced life support unit.

Complications

  • The principle effect of cocaine, like ethanol, on mortality may be its association with homicide, suicide, and motor vehicle collisions.39 In a study of 14,843 persons who were fatally injured in New York City over 3 years, fatal injury after cocaine use exceeded all deaths associated with other causes in persons aged 15-24 years. Although approximately one third of deaths associated with cocaine use were the result of its direct pharmacologic effects, two thirds were the result of traumatic injuries.
    • Cocaine use, determined by detection of its metabolite benzoylecgonine in urine or blood, was found in 26.7% of the above-mentioned patients, with free cocaine, indicating recent use, detected in 18.3%. Ethanol was detected in 28.1% of those who died. For comparison, household surveys of the general population of New York City showed that the estimated frequency of cocaine use in the preceding 30 days was less than 1.3% overall; demographic groups with the highest rates of use were Hispanics and black men, whose rates were 3-4.1%.
    • In this study, cocaine use was detected in 69.7% of all cases of accidental poisonings, 29.2% of homicides, 15.3% of suicides, and 9.3% of accidents.
  • The use of alcohol and illicit drugs increases the risk of suicide 16-fold, which is substantially higher than the rate observed with either substance alone. A study of suicide cases in New York City demonstrated that 20% of individuals younger than 61 years had used cocaine within days of their death. Nearly one half of Hispanic men who commit suicide have toxicologic screens positive for cocaine. Cocaine users typically choose violent means for self-destruction, especially the use of firearms.
    • Illicit use of drugs by members of the household increases a woman's risk of death at the hands of a spouse, lover, or close relative 28-fold.
    • According to Brookoff, approximately 45% of assailants in domestic violence had used alcohol or other drugs to the point of intoxication on a daily basis for the previous month.40 Approximately 12% were addicted to drugs, and 14% were addicted to alcohol and drugs. On the day of the assault, the most common intoxicant was cocaine. About 30% of assailants had used cocaine and alcohol, and 13% had used alcohol, marijuana, and cocaine.
    • In another study of domestic violence, two thirds of assailants had used the combination of alcohol and cocaine on the day of the assault. The active metabolite of this drug combination, cocaethylene, is more intoxicating, longer lived, and possibly more potent in its ability to kindle violent behavior than the parent drugs.
  • For individuals with one addictive disorder, the risk of having a second addictive disorder is increased 7-fold.
  • People who use cocaine have an increased incidence of acquiring HIV and other sexually transmitted infections.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider cocaine toxicity in a hyperadrenergic patient, thus precipitating an alpha-adrenergic crisis after administration of a beta-adrenergic blocking drug without addressing the increased alpha-adrenergic activity
  • Failure to monitor the patient's core temperature, administer sedation, adequate IV fluids, and cooling measures to prevent or halt the progression of rhabdomyolysis
  • Failure to consider drug interactions in a hyperadrenergic patient and contributing to these interactions by administering a drug with potentially detrimental effects (eg, meperidine use in serotonin syndrome)
  • Failure to hydrate and alkalinize the urine, thereby increasing the likelihood of renal failure secondary to rhabdomyolysis
  • Failure to consider and evaluate all potential causes of agitated delirium, such as trauma or infection
  • Failure to consider secondary complications (eg, barotrauma, sepsis, rhabdomyolysis, ischemia or infarction of organs)
  • Failure to consider body packing or body stuffing such as in the assessment of patients with prolonged toxicity or in those with otherwise unexplained hyperactivity after arrest or incarceration

Special Concerns

  • Pregnant patients
    • A study in the 1990s by NIDA revealed that more than 220,000 women had used an illicit drug during their pregnancy, and more than one fifth of these women had used cocaine in powdered or crack form.
    • Cocaine and its metabolites rapidly cross the placenta. Fetal levels approach 15% of maternal levels in 3-5 minutes. Cocaine plasma levels and vasoconstriction of uterine artery have a dose-dependent inverse relationship, resulting in an increased fetal BP and heart rate and decreased oxygen content (and other nutrients) in fetal blood. Thus, decreased placental blood flow results in chronic fetal hypoxemia. Some studies have demonstrated that cocaine reduces the uptake of nutrient substances in placental villi, even in the absence of vascular tissue. Other findings have suggested that cocaine exerts direct toxic effects on fetal myocytes.
    • Cocaine use in early pregnancy is associated with increased risk of spontaneous abortion or embryonic death with expulsion or resorption.
    • Late pregnancy complications include premature labor and delivery, precipitous delivery, placental abruption (which occurs twice as often as in drug-free control subjects), low birth weight, intrauterine growth retardation, low Apgar scores, meconium staining, fetal demise, and stillbirth.
  • Pediatric patients
    • Infants and toddlers have increased susceptibility to cocaine toxicity, possibly secondary to decreased activity of plasma and hepatic cholinesterase.
    • In a study of 43 infants who died within 2 days of birth and whose autopsies failed to reveal an obvious cause of death, 40% had toxicologic evidence of cocaine exposure.
    • Cocaine withdrawal syndrome is common in neonatal intensive care units (NICUs). If the infant is discharged before the problem is recognized, the patient may later present to the ED. Treatment is symptomatic, with use of benzodiazepines.
    • Ostrea, Ostrea, and Simpson report a study of 2964 infants. Of the infants whose mothers denied having a history of illegal drug use, 34.4% screened positive for drugs. A high perinatal morbidity rate was observed in drug-positive infants with significantly low birth weight, head circumference, and length. The incidence of SIDS was not significantly increased among drug-positive infants overall. Low birth weight and prematurity are known consequences of drug use during pregnancy; low-birth-weight babies (2500 g or less) have a significantly increased mortality rate.41
    • Although a number of structural and developmental abnormalities, including congenital cardiovascular malformations, have been noted in babies with cocaine toxicity, no specific teratogenic syndrome has been identified.
    • Seizure activity is common in neonates with cocaine exposure. These babies are at increased risk for intracerebral and intraventricular hemorrhage; focal seizures may indicate cerebral infarction of the newborn.
    • In neonates, infants, and toddlers, seizures have been precipitated by breastfeeding from a mother using cocaine, passive inhalation of smoke from crack cocaine, and accidental ingestion.
    • Even when the child is no longer exposed to cocaine, his or her cardiovascular abnormalities, including structural and functional abnormalities of the ventricle, intracardiac conduction delays, and dysrhythmias, may persist. These may result in CHF and cardiorespiratory arrest.
    • Cocaine can cause necrotizing enterocolitis in infants.
    • Another risk is child abuse or neglect. In a study of 100 cocaine-exposed infants and socioeconomically matched control infants followed for up for 2 years, 7 were physically injured, 37 were neglected, and 21 were placed in substitute care. The control group of infants not exposed to cocaine had no instances of abuse or neglect.42
 


More on Toxicity, Cocaine

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

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Further Reading

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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

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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.

 
 
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