Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Cocaine Toxicity Treatment & Management

  • Author: Lynn Barkley Burnett, MD, EdD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Jun 30, 2016
 

Prehospital Care

Prehospital care includes the following:

  • Assess the patient's airway, breathing, and circulation (ABCs); intervene if necessary
  • Provide oxygen
  • Obtain intravenous access
  • Closely monitor vital signs, including temperature
  • Monitor glucose levels for patients with altered mental status
  • Carefully use naloxone for patients with altered mental status, if opioid use cannot be excluded
  • Administer benzodiazepines to manage seizures

Patients with cocaine toxicity may be combative, aggressive, and disoriented, and have delusions of persecution or hallucinations. Caution is appropriate because the patient may attempt to harm care providers. Physical restraint should be avoided if possible due to risks of rhabdomyolysis and hyperthermia. When physical restraint is required it should be used only with caution and adequate personnel.

Next

Emergency Department Care

Patients with cocaine toxicity should receive initial evaluation and stabilization, including attention to ABCs, oxygen, intravenous access, and cardiac and pulse oximetry monitoring.

In hyperthermic patients, temperature may continue to rise secondary to agitation and potentially to fighting of restraints. Temperature may reach critical levels; thus, close monitoring and early intervention is indicated.

Check the nares for residual cocaine, and remove if present.

Monitor for hypoglycemia, which may present as any neuropsychiatric abnormality

Never base treatment on the results of a drug screen; rely on clinical findings instead.

Avoid physical restraints if possible. Benzodiazepines are an effective and safe pharmacologic restraint if required.

Prevalence of unrecognized pregnancy is up to 6% in ED patients. Perform routine pregnancy testing for appropriate patients as physiologic changes in pregnancy may increase cocaine toxicity. Cocaine may induce miscarriage, premature labor, or fetal toxicity, and modifications may be necessary for acute management.

Provide reassurance. The effects of cocaine are generally short lived. Monitor patients until they are no longer tachycardic and hypertensive and until they are calm and cooperative.

Previous
Next

Therapeutic Dilemmas

Medications commonly administered to treat pathophysiologic effects of cocaine may worsen other adverse effects of cocaine. Thus, there is concern primarily about use of epinephrine, lidocaine, and beta-blockers in the setting of acute cocaine toxicity. Conflicting reports and recommendations in the literature compound the controversy.

As an example, the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care acknowledge that many toxicologic approaches are not based on high-quality research, but rather on case reports, small case series, and data extrapolated from animal studies. The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2012 recommendations for treatment of patients with cocaine toxicity are based on class C evidence  (ie, consensus opinion of experts, case studies, or standard of care).[38]

Epinephrine and vasopressin

Vasopressin offers considerable theoretical advantage over epinephrine in cardiac arrest secondary to cocaine toxicity.[39, 40] The hyperadrenergic state caused by cocaine increases myocardial oxygen demand. Epinephrine has the same effect. Vasopressin, on the other hand, increases coronary blood flow and myocardial oxygen availability.[41] Cocaine toxicity frequently causes acidosis: epinephrine loses much of its effectiveness in an acidotic milieu[41] , whereas vasopressin demonstrates vasoconstricting efficacy even with severe acidosis.[42]

Epinephrine has been the drug of choice for the treatment of cardiac arrest, primarily for its alpha-adrenergic effects. However, epinephrine and cocaine have many similar cardiovascular effects. Furthermore, cocaine prevents the reuptake of exogenously administered epinephrine. Therefore, if epinephrine is used, the AHA Textbook of Advanced Cardiac Life Support for the Experienced Provider recommends that high-dose epinephrine be avoided and that the interval for its administration be increased (q5-10 min).

If ventricular fibrillation or ventricular tachycardia is recurrent or refractory and epinephrine or excessive levels of endogenous catecholamines are the suspected cause, consider withholding further doses of epinephrine. Because of similarity in cardiovascular effects caused by cocaine and epinephrine, administration of epinephrine to a patient who arrests in a hyperadrenergic state has been likened to "pouring gasoline on a fire."[40]

Lidocaine

Although some animal data indicate that lidocaine can reverse the ECG effects of cocaine and protect against death, others indicate that lidocaine may lower the seizure threshold and potentiate cocaine toxicity. Derlet, Tseng, and Albertson caution that lidocaine potentiates the CNS toxicity of cocaine.[43] Noting this small "safety window," Derlet states that lidocaine may be used, but advises precautions, such as double- or triple-checking the total dose, solution concentration, and any infusion pump.[44]

Cocaine and lidocaine have similar pharmacologic effects. Therefore, the possibility that lidocaine may increase toxicity by potentiating the effects of cocaine on the cardiovascular system has been a concern.

The AHA Textbook of Advanced Cardiac Life Support for the Experienced Provider cites this similarity for the therapeutic role that lidocaine may play in competing with cocaine at the sodium channel, thereby decreasing the effects of cocaine.

In the setting of cocaine toxicity, the decision as to whether or not to use lidocaine must be carefully considered, weighing its potential benefit on ventricular rhythm disturbances versus the synergistic toxic effects of lidocaine on seizure risk.

Beta-blockers

The 2012 ACCF/AHA guidelines on unstable angina and non–ST-segment elevation myocardial infarction advise that the use of beta-blockers within 4 to 6 hours after cocaine exposure is controversial, with some evidence for harm. Instead, the guidelines recommend that a combined alpha- and beta-blocking agent (eg, labetalol) may be a reasonable treatment choice for cocaine-related hypertension (systolic blood pressure >150 mm Hg) or sinus tachycardia (pulse >100 beats per min), provided that the patient has received a vasodilator, such as nitroglycerin or a calcium channel blocker, within the past hour.[38]

However, labetalol has an alpha-to-beta blockade ratio of 1:7. Therefore, it may not provide enough protection for cocaine-toxic patients from (relatively) unopposed alpha stimulation. Its risk of exacerbating myocardial ischemia parallels the risk of beta-blockers. Labetalol also increased seizures and mortality in animal models. Nevertheless, a systematic review of cocaine-related cardiovascular toxicity found that combined alpha/beta-blockers such as labetalol and carvedilol were effective in attenuating both hypertension and tachycardia, with no adverse events reported.[45]

AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care advise that although evidence of benefit exists, the current recommendation is that pure beta-blockers are not indicated for the treatment of cocaine-related cardiac toxicity.[46]

 

 

Previous
Next

Cardiovascular Concerns

Cocaine-associated cardiac arrest

Current American Heart Association (AHA) guidelines note that no data exist to support the use of cocaine-specific interventions in cardiac arrest due to cocaine overdose. Instead, resuscitation should follow standard Basic Life Support and Advanced Cardiac Life Support algorithms(ACLS).[46]

Cocaine-associated acute coronary syndrome

The AHA guidelines note that clear evidence exists that cocaine can precipitate acute coronary syndrome (ACS), and it may be reasonable to try agents that have shown efficacy in the management of ACS in patients with severe cardiovascular toxicity. Agents that may be used as needed to control hypertension, tachycardia, and agitation include the following[46] :

  • Alpha-blockers (phentolamine)
  • Benzodiazepines (lorazepam, diazepam)
  • Calcium channel blockers (verapamil)
  • Morphine
  • Sublingual nitroglycerin (NTG)

The AHA does not recommend any one of those agents over another in the treatment of cardiovascular toxicity due to cocaine.

Cocaine-associated cardiac dysrhythmias

Ventricular ectopy is usually transient and is managed with careful observation and escalating doses of benzodiazepine to blunt the hypersympathetic state by modulating cocaine-induced CNS stimulation. Treat malignant ventricular ectopy and perfusing ventricular tachycardia (VT) by ensuring good oxygenation, by treating the hyperadrenergic state with escalating doses of benzodiazepine, and by administering appropriate antidysrhythmic medications if ventricular arrhythmias persist. Ensure that a defibrillator is readily available.

Consider sodium bicarbonate for treating dysrhythmias resulting from the direct toxic effects of cocaine,[47] such as when sodium channel blockade causes a QRS >100 milliseconds. Dual mechanisms of action have been proposed for its therapeutic effects: (1) Alterations in pH may change the conformation of the sodium channel, and (2) increased extracellular sodium concentrations may override sodium channel blockade. Hourly measurements of blood pH are indicated, with appropriate adjustments until the blood pH is properly controlled. End points of bicarbonate therapy are a serum pH of 7.50-7.55.

Paroxysmal supraventricular tachycardia (PSVT), atrial flutter, and rapid atrial fibrillation are generally short-lived and do not require immediate treatment. Use escalating doses of benzodiazepine to treat hemodynamically stable patients with persistent supraventricular arrhythmias to blunt the hypersympathetic state by modulating cocaine-induced stimulation of the CNS, taking caution not to depress consciousness and create a need for respiratory assistance.

In drug-induced hemodynamically significant tachycardia, the pathophysiologic mechanism responsible may be increased automaticity, triggered activity, or reentry phenomenon. Tachycardia caused by increased automaticity will not be responsive to interventions such as adenosine and synchronized cardioversion. Benzodiazepines are generally safe and effective in drug-induced hemodynamically significant tachycardia

Cocaine-associated chest pain and MI

Chest pain may result from musculoskeletal, cardiovascular, pulmonary, or other causes. Risk of myocardial infarction is highest within the first hour following cocaine use.[48] In patients with cocaine-related chest pain, assume that cardiac ischemia is present until this is proven otherwise. Accordingly, the ED approach to such patients, in addition to oxygen, intravenous access, and monitoring, includes the steps outlined below.

  • Perform 12-lead ECG.
  • Obtain chest imaging.
  • Direct the initial pharmacologic approach to suspected cocaine-related myocardial ischemia at increasing coronary blood flow and decreasing sympathetic output.

The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2012 guidelines on unstable angina and non–ST-segment elevation myocardial infarction include the following class I recommendations for treatment of patients with ischemic chest discomfort and  ST-segment elevation or depression after cocaine use[38] :

  • Administer sublingual or intravenous (IV) NTG and IV or oral calcium channel blockers (eg, diltiazem, 20 mg IV)
  • In patients whose ST segments remain elevated after NTG and calcium channel blockers, perform immediate coronary angiography, if possible; if occlusive thrombus is detected, percutaneous coronary intervention is recommended
  • Fibrinolytic therapy is useful in patients with ischemic chest discomfort after cocaine use if ST segments remain elevated despite NTG and calcium channel blockers and coronary angiography is not possible; however, fibrinolysis is often contraindicated

AHA guidelines note that patients with cocaine-induced hypertension or chest discomfort may also benefit from benzodiazepines and/or morphine, in addition to NTG.[46]

Small, incremental doses of benzodiazepines decrease norepinephrine release by the CNS, thereby counteracting the sympathomimetic effects of cocaine on the heart. Similar doses of morphine sulfate (MS) also alter hemodynamics and blood flow dramatically in patients with heightened sympathetic activity. Limiting factors for morphine and benzodiazepines include hypotension, somnolence, and respiratory depression. Kercher cautions that short-acting benzodiazepines (eg, lorazepam) should be prescribed at low doses for patients with hepatic disease, organic brain syndrome, and those taking medications inhibiting the metabolism and clearance of benzodiazepines (eg, those using nicotine or cimetidine).[49]

In patients with prolonged unexplained chest pain, perform serial ECGs and cardiac-marker measurements to rule out MI. However, in one study, Hollander reports that patients with MI were as likely to present with normal or nonspecific ECG findings as with ischemic ECG findings. The sensitivity of the ECG in predicting MI was only 35.7%; therefore, ECG appears to be less sensitive in patients with cocaine-induced myocardial ischemia than in other patients presenting with ischemic chest pain.

Interpretation of cardiac markers in patients with cocaine-induced symptoms may be difficult since levels of creatine kinase (CK) and CK MB-isoform (CK-MB) may be elevated in cocaine users who do not have an MI. However, the specificity of troponin assays is not affected by cocaine use.[26]

Be mindful that as many as 43% of patients with cocaine-related chest pain meet standard ECG criteria for fibrinolysis despite being cardiac marker negative for infarction; a high percentage of such patients have early repolarization.

Of additional importance, an increased incidence of mycotic aneurysms and CNS mass lesions may lead to an increased incidence of hemorrhagic complications in these patients. When evaluating patients for fibrinolytic therapy, remember that a history of intravenous drug use poses a relatively high risk for the possibility of coexisting vascular pathology.[47] Obtain a detailed history and perform physical and ancillary testing, as appropriate, directed at identifying endocarditis, septic pulmonary emboli, and pseudoaneurysm.

AHA 2005 Guidelines state that intracoronary administration of fibrinolytics is preferred to blind peripheral administration in patients with drug-induced acute coronary syndrome. Fibrinolysis in the presence of hypertension or CNS vasculitis may be dangerous, and percutaneous transluminal coronary angioplasty (PTCA) may be a safer alternative when revascularization is indicated.

In light of the above confounding factors, the AHA Textbook of Advanced Cardiac Life Support for the Experienced Provider indicates that cardiac catheterization is recommended by many experts.

Fibrinolysis should thus be reserved for patients who cannot receive percutaneous coronary intervention within the requisite time and who have low risk for cerebrovascular bleeding and other hemorrhagic complications of fibrinolytic therapy.

Patients may develop chest pain several hours after cocaine use.[27] Recurrent coronary vasoconstriction associated with increased levels of benzoylecgonine and ethyl-methyl ecgonine may be responsible. Furthermore, patients with cocaine withdrawal may have dopamine depletion, resulting in intermittent coronary spasm.[36] MI has been attributed to cocaine use several days earlier, and Holter monitoring has documented cocaine-induced ischemia for several weeks after cocaine use.[27] Recurrent ischemic chest pain is reported in patients who do and in patients who do not continue to abuse cocaine.[27] Ischemia may persist for up to 2 weeks after the cessation of cocaine use; therefore, avoiding the use of beta-adrenergic blockade for as long as 2 weeks after withdrawal of the toxin may be prudent.

Objective assessment may aid decision-making when the patient's treatment or disposition may be altered in the presence of cocaine.[22] For example, beta-blockers are relatively contraindicated in cocaine use, but they are commonly given when cocaine is not considered a factor in myocardial injury or ischemia. However, in one study, 28% of patients with chest discomfort who tested positive for cocaine had denied using it. When beta-adrenergic blockade is being considered, even if cocaine toxicity is not suspected, a rapid bedside test for cocaine use may be appropriate because of its prevalence and the substantial rate of false-negative findings in the history of present illness.

Hypertension

Cocaine may precipitate hypertensive emergency due to CNS stimulation and peripheral alpha-agonist effects. Toxicity may be superimposed on preexisting hypertension in patients who have become dependent on elevated BP to maintain cerebral perfusion. Carefully consider the patient's clinical status and history when deciding to treat hypertension.

Hypertension secondary to cocaine is commonly responsive to intravenous benzodiazepines, because benzodiazepines minimize the stimulant effects of cocaine on the CNS.

A vasodilator, such as NTG or nitroprusside, may be titrated to effect if further therapy is indicated. NTG is the drug of choice in patients with chest pain. The use of nitroprusside to control hypertension has the additional advantage of aiding heat loss by peripheral vasodilatation.

Hypotension

Hypotension may be treated with parenteral fluids and, if refractory to fluids, norepinephrine, a direct-acting pressor, is preferred over indirect agents like epinephrine.

Aortic dissection

Include type A aortic dissection in the differential diagnosis of cocaine abuse with chest pain. ED care entails close cardiac and hemodynamic monitoring, treatment to reduce the progression of dissection, and administration of narcotics as needed for pain. Sodium nitroprusside should be used to control BP, but it may cause tachycardia, for which esmolol may be considered. Although the goals of therapy are to decrease the heart rate to 60-80 bpm and BP to 100-120 mm Hg, the therapeutic endpoint is the lowest level that permits continued end-organ perfusion.

Previous
Next

Pulmonary Concerns

Cocaine affects pulmonary dynamics and may cause pulmonary edema. Other causes of pulmonary edema in the setting of cocaine use include CHF (with or without MI) and subarachnoid hemorrhage or concomitant use of other drugs (eg, heroin). Most patients with cocaine-associated pulmonary edema respond to standard medical treatment.

For resistant hypoxemia, positive-pressure ventilation with continuous positive airway pressure (CPAP) or intubation supplemented with positive end-expiratory pressure (PEEP) is usually effective. For patients with respiratory depression intubation may be indicated, as it is for those with apnea.

Administration of naloxone to a patient who has been speedballing may negate the sedative effect of the opioid and leave the stimulant effect of the cocaine unopposed, precipitating or worsening cocaine toxicity. Naloxone is still indicated in respiratory depression but should be used with caution (ie, slowed rate of administration, lowered doses).

Administration of flumazenil to patients with benzodiazepine use (eg, to blunt the effects of cocaine) may be dangerous. Cocaine is a gamma-aminobutyric acid (GABA) antagonist that may be blocked by benzodiazepines and potentiated by flumazenil. Use of flumazenil in the cocaine-intoxicated patient may induce seizures.

Previous
Next

Neurologic Concerns

Seizures are a concern. Cocaine is one of the most common causes of drug- and toxin-associated seizures. Seizures may be a dire sign of toxicity that heralds life-threatening physiologic instability. Cocaine-associated seizures are usually generalized, but they may be partial. They may result directly from toxicity of the CNS or indirectly from hypoxemia, stroke, or other conditions. They may occur after recreational use, long-term abuse, or cocaine overdose. Seizures also occur in people who pack or stuff cocaine in their body, affecting 4% of patients who are body stuffers, with seizures expected in the first 2 hours.

Seizures occurring from cocaine toxicity are managed as part of comprehensive patient treatment. Seizures and severe agitation require prompt attention to protect the airway and prevent hyperthermia. Although patients with serious compromise may require paralysis and mechanical ventilation, benzodiazepines are first-line therapy. Benzodiazepines directly enhance GABA-mediated neuronal inhibition, affecting the clinical and electrical manifestations. Their overall effectiveness in terminating cocaine-induced seizures is 75-90%.

Although Perrone and Hoffman recommend head CT in all cases of cocaine-associated seizures because of the risk of associated intracranial lesions,[36] Renzi believes that a brief seizure, clearly temporally related to cocaine use, requires no further workup if the patient is otherwise healthy, alert, coherent, without headache, and neurologically intact.[37] If patients are not admitted, monitor them in the ED for several hours.

Previous
Next

Dystonic Reactions

Emotional distress can exacerbate dystonic reactions, whereas relaxation may reduce the intensity of such attacks. Using a calm reasoned approach in a quiet room markedly complements the effectiveness of pharmacologic interventions.

Dopamine and acetylcholine have mutually antagonistic functions in the nigrostriatal system. Although diphenhydramine, with its anticholinergic properties, is the drug of choice for most dystonic reactions, it should be used with caution in cocaine toxicity. Antihistamines cause hyperthermia by central (eg, hypothalamic) and peripheral (inhibition of sweating and muscular rigidity) effects; cocaine also causes hyperthermia. Antihistamines and cocaine are sodium channel blockers. Therefore, coadministration of an antihistamine in the setting of cocaine use may potentiate a molecular pathophysiological cascade that exacerbates end-organ dysfunction.

Benzodiazepines, with their anxiolytic and muscle relaxant properties, are alternative drugs for the treatment of dystonia. Although they only treat the manifestations of dystonias and not the pathophysiology underlying their development; the advantage of using benzodiazepines lies in their safety.

Previous
Next

Metabolic Concerns

Hypoglycemia may present as any neuropsychiatric syndrome and is always a consideration in patients who present with altered mental status or convulsions. Rapid diagnosis by meter or Dextrostix prevents the deleterious effects reported for the administration of dextrose in the absence of hypoglycemia. If the adult patient is hypoglycemic, administer thiamine 100 mg followed by 50 mL of 50% dextrose (D50W).

Acidosis has a profoundly adverse effect on myocardial contractility and may potentiate the effect of catecholamines. The correction of arterial pH, through ventilatory assistance and appropriate use of sodium bicarbonate, may be effective in terminating cocaine-induced dysrhythmias with resulting improvement of hemodynamics.

Previous
Next

Hyperthermia

Recognize and treat hyperthermia as a distinct entity. If psychostimulant-intoxicated patients do not die as a result of cardiac or cerebrovascular complications, the next most important steps in preventing further morbidity are control of hyperthermia and treatment of rhabdomyolysis. Assess the patient's core body temperature and maintain a high index of suspicion for hyperthermia. In the setting of serious hyperthermia, continuously monitor the core body temperature.

Hyperthermia may be treated with convection cooling, which involves spraying the patient's exposed body with tepid water as fans circulate air. Tepid water prevents maladaptive shivering that may be induced by conduction cooling methods, although ice packs, ice water gastric lavage, or cooling blankets may also be used. Direct efforts at reducing body temperature to 101ºF in 30-45 minutes.

Do not use restraints (physical or pharmacologic) that interfere with dissolution of heat. If necessary, use light hand and foot restraints. Ensure adequacy of hydration and electrolytes. Benzodiazepines are an effective and safe pharmacologic restraint in these patients. Given parenterally, with the usual precautions, they rapidly calm hyperactive patients.

Do not administer phenothiazines. Goldfrank, Flomenbaum, Lewin, and Weisman apply this injunction to butyrophenones as well.[50] Contrary views are, however, expressed in the literature. Callaway and Clark maintain that concerns about the potentiation of drug-induced seizures by butyrophenone neuroleptics (eg, haloperidol) may be exaggerated because such drugs have less effect on human seizure threshold than phenothiazines, and they interfere less with sweat-mediated evaporative cooling in drug-induced hyperthermia.[16] Although Callaway and Clark believe that further studies are necessary to assess the efficacy of butyrophenones in the treatment of psychostimulant overdose,[16] Colucciello and Tomaszewski indicate that haloperidol is effective in treating cocaine-related agitation and that no clinical data proscribe its use, theoretic concerns notwithstanding.[51]

Monitor patients with hyperthermia in the ED for several hours if they are not being admitted.

Previous
Next

Cocaine-Induced Rhabdomyolysis

The reported incidence of rhabdomyolysis in ED patients who use cocaine is 5-30%. Pathophysiologic hypotheses include placement of excessive demands on healthy muscle cells that cannot be met by available energy supplies, direct toxicity of cocaine upon the muscle membrane, cocaine-induced seizures, and the potential concomitant use of other drugs (eg, PCP, amphetamines) that are known to cause this syndrome.

Risk factors for rhabdomyolysis include altered mental status, hyperactivity, fever, seizures, hypotension, dysrhythmias, and cardiac arrest. Rhabdomyolysis may be associated with hyperphosphatemia, myoglobinuria, nephrotoxicity, hyperkalemia, hypocalcemia, compartment syndromes, or disseminated intravascular coagulation (DIC). The most critical sequelae of rhabdomyolysis are shock and renal failure.

Rapid fluid resuscitation promotes urine output and alleviates the effect of myoglobin on the kidneys. Generous amounts of intravenous fluids with close monitoring of urine output and pH are indicated for rhabdomyolysis associated with severe psychostimulant toxicity. Fluid resuscitation should maintain urine output of 1-3 mL/kg/h to minimize renal damage from rhabdomyolysis. Patients with rhabdomyolysis may require up to 20 L of fluid in the first 24 hours to achieve these urinary flow rates, and close monitoring of cardiac status and electrolytes is necessary.

In acid urine, myoglobin is essentially a toxin, and uric acid tends to crystallize at low pH; sodium bicarbonate may be used to alkalinize the urine of patents with rhabdomyolysis. However, without prospective randomized studies to differentiate the role played by volume versus alkalinization, it is possible that volume alone represents maximally effective therapy. This is important because cocaine metabolites are best excreted in acid urine, and it calls into question the role of urinary alkalinization.

Previous
Next

GI concerns

When cocaine has been ingested (not as part of body packing or body stuffing), the patient without altered mental status may be treated by administration of activated aqueous charcoal. Gastric lavage and induction of vomiting via ipecac syrup is not recommended because of the risk of seizure, with the potential for airway compromise and aspiration of vomitus.

Previous
Next

Body Packing and Body Stuffing

In body packers, although a risk for toxicity exists, the drugs are often carefully packaged to prevent rupture or leakage. Carriers often purge the GI tract with a laxative before they ingest the drug packages and then consume only clear liquids until the drugs are delivered. If a constipating agent was used, they ingest a laxative to enhance evacuation when arriving at their destination.

Conversely, body stuffers quickly ingest drug packages to avoid arrest. Therefore, body stuffers are at increased risk for aspiration because of the rapidity with which they attempt to remove the evidence from police accessibility. Bronchoscopy has been used to successfully remove a drug packet aspirated into the lung.

Body stuffers have other risks as well. Because they were not planning to ingest the packet (as opposed to the body packer) and because they took no precautions selecting the drug container, the wrapping material often acts as a semipermeable membrane. The hypertonic content of the drug packet attracts water, making the ingested packages especially prone to rupture or leakage resulting in toxicity.

Potent polypharmaceutic overdose is also common, resulting from an attempt to swallow all of the illegal drugs on site.

The administration of activated charcoal has been recommended to adsorb any toxins from leaking bags, from ruptured bags, or that were liberated during enhancement of bowel transit (eg, whole-bowel irrigation). Treatment of asymptomatic patients should include laxatives (eg, sodium sulfate, magnesium sulfate, magnesium citrate, psyllium hydrophilic mucilage) or whole-bowel irrigation, several doses of activated charcoal, and close observation.

If a polyethylene glycol electrolyte lavage solution (eg, GoLYTELY, Colyte) is to be used for whole-bowel irrigation, Malbrain cautions that it must follow the administration of activated charcoal because the maximal adsorptive capacity of activated charcoal is at pH 7 and the polyethylene glycol electrolyte lavage solution has a pH of 8.[52] Do not use paraffin-containing laxatives (eg, Lansoyl) because they degrade latex. Avoid endoscopic manipulation and enemas because the drug packet may be ruptured. Contraindications to whole-bowel irrigation include ileus, GI hemorrhage, or bowel perforation.

Body stuffers should be observed, including cardiac monitoring, for 6 or more hours.[53] Body packers may require hours to days of hospitalization until all the packets have been passed. Surgical intervention is needed if patients present with serious signs or symptoms or intestinal obstruction.

Previous
Next

Psychiatric Concerns

Individuals using cocaine expect to become euphoric, energetic, and confident. However, with large doses or prolonged use, they may become agitated, anxious, or panicky. A wild, combative patient intoxicated with cocaine may be sedated with lorazepam or midazolam, both of which can be adequately absorbed via the intramuscular route if intravenous access is unobtainable.

Given the contradictory literature about butyrophenones that was previously addressed, attempt to avoid use of antipsychotics because they may confuse the clinical picture, exacerbate anticholinergic crisis, lower the seizure threshold, or cause a dystonic reaction.

Previous
Next

Other Considerations

When treating a traveler who presents with fever, bizarre mental state, or coma, especially if the person has come from West Africa or South America, consider cerebral malaria, treated with intravenous quinine.

Test patients who inject drugs for HIV and hepatitis (with their permission, if required by state law).

If a patient with cocaine toxicity is being considered as an organ donor, remember that cocaine preferentially accumulates in the liver and kidney. Therefore, use of these organs may result in the transplantation of a substantial reservoir of the toxin.

Previous
Next

Topiramate

In a 12-week, double-blind, randomized study involving 142 cocaine-dependent adults, treatment with the anticonvulsant topiramate was found to be significantly more effective than placebo in improving abstinence from cocaine use, reducing the intensity and frequency of cravings for cocaine in a 24-hour period, and improving observer-rated global functioning.[54, 55]

From weeks 6-12, half of the study’s patients received escalating doses of topiramate, starting at 50 mg daily and increasing to the target maintenance dose of 300 mg/day. The reduction from baseline in the number of days per week in which patients did not use cocaine was 13.3% with topiramate, compared with 5.3% with placebo. In addition, the likelihood of achieving urinary cocaine–free weeks increased by 16.6% with topiramate, versus 5.8% with placebo.

Previous
Next

Consultations

Consultation with a regional poison control center or a medical toxicologist may be appropriate in complicated cases.

Previous
 
 
Contributor Information and Disclosures
Author

Lynn Barkley Burnett, MD, EdD LLB(c), Medical Advisor, Fresno County Sheriff's Office; Attending Consultant-in-Chief and Chairman, Medical Ethics, Community Medical Centers; Adjunct Assistant Clinical Professor of Emergency Medicine and Forensic Pathology, Touro University College of Osteopathic Medicine, California; Core Graduate Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program; Core Graduate Adjunct Professor of Leadership in Healthcare, Health Law and Healthcare Ethics, Kaplan University Graduate School of Healthcare Administration

Lynn Barkley Burnett, MD, EdD 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 Public Health Association, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Association of Military Surgeons of the US, Christian Medical and Dental Associations, European Society of Cardiology, New York Academy of Sciences, Royal Society of Medicine, Society for Academic Emergency Medicine, Society of Critical Care Medicine, American Professional Society on the Abuse of Children, American Stroke Association, Royal College of Surgeons of Edinburgh, World Association for Disaster and Emergency Medicine, European Society of Intensive Care Medicine, European Society of Paediatric and Neonatal Intensive Care, European Society for Trauma and Emergency Surgery, International Homicide Investigators Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan Adler, MD, MS Instructor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital

Jonathan Adler, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Carlos J Roldan, MD, FAAEM, FACEP Associate Professor, Department of Emergency Medicine, University of Texas Health Science Center at Houston Medical School; Consulting Staff, Department of Emergency Medicine, Memorial Hermann Hospital Lyndon Baines General Hospital and MD Anderson Cancer Center

Carlos J Roldan, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Pain Society, American Society of Regional Anesthesia and Pain Medicine, International Association for the Study of Pain, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, Texas Medical Association, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

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

  2. Paczynski RP, Gold MS. Cocaine and Crack. Ruiz P, Strain EC. Lowinson and Ruiz's Substance Abuse: A Comprehensive Text. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011. 191-213.

  3. The Drug Abuse Warning Network. Highlights of the 2010 Drug AbuseWarning Network (DAWN) Findings onDrug-Related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. Available at http://www.samhsa.gov/data/2k12/DAWN096/SR096EDHighlights2010.pdf. Accessed: September 2012.

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

  5. Signs SA, Dickey-White HI, Vanek VW, Perch S, Schechter MD, Kulics AT. The formation of cocaethylene and clinical presentation of ED patients testing positive for the use of cocaine and ethanol. Am J Emerg Med. 1996 Nov. 14(7):665-70. [Medline].

  6. Zhu NY, Legatt DF, Turner AR. Agranulocytosis after consumption of cocaine adulterated with levamisole. Ann Intern Med. 2009 Feb 17. 150(4):287-9. [Medline].

  7. Liu YW, Mutnuri S, Siddiqui SB, Weikle GR, Oladipo O, Ganti N, et al. Levamisole-Adulterated Cocaine Nephrotoxicity:  Ultrastructural Features. Am J Clin Pathol. 2016 May. 145 (5):720-6. [Medline].

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

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

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

  11. 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. 1994 Jul-Aug. 1(4):330-9. [Medline].

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

  13. Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J Forensic Sci. 1997 Jan. 42(1):25-31. [Medline].

  14. Vilke GM, Bozeman WP, Dawes DM, Demers G, Wilson MP. Excited delirium syndrome (ExDS): treatment options and considerations. J Forensic Leg Med. 2012 Apr. 19(3):117-21. [Medline].

  15. Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome (ExDS): redefining an old diagnosis. J Forensic Leg Med. 2012 Jan. 19(1):7-11. [Medline].

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

  17. Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. 2015. Available at http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.

  18. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. HHS Publication No. (SMA) 13-4760, DAWN Series D-39: [Full Text].

  19. Liakoni E, Dolder PC, Rentsch KM, Liechti ME. Presentations due to acute toxicity of psychoactive substances in an urban emergency department in Switzerland: a case series. BMC Pharmacol Toxicol. 2016 May 26. 17 (1):25. [Medline].

  20. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2010: Area Profiles of Drug-Related Mortality. HHS Publication No. (SMA) 12-4699, DAWN Series D-36. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. [Full Text].

  21. 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). 1996 Jun. 125(4):346-54. [Medline].

  22. 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. 1995 Dec. 26(6):671-6. [Medline].

  23. California. Turner died of overdose. The New York Times. January 17, 2008. A23.

  24. Hiestand BC, Smith SW. Cocaine chest pain: between a (crack) rock and a hard place... Acad Emerg Med. 2011 Jan. 18(1):68-71. [Medline].

  25. 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://www.cocainehelp.org/upload/dl/Crack_Cocaine_and_General_Addiction_Research/DAWN2k4ED.pdf.

  26. Finkel JB, Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011 Dec. 86(12):1198-207. [Medline].

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

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

  29. Byard RW. Acute mesenteric ischaemia and unexpected death. J Forensic Leg Med. 2012 May. 19(4):185-90. [Medline].

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

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

  32. Rivara FP, Mueller BA, Somes G, Mendoza CT, Rushforth NB, Kellermann AL. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA. 1997 Aug 20. 278(7):569-75. [Medline].

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

  34. Meehan TJ, Bryant SM, Aks SE. Drugs of abuse: the highs and lows of altered mental states in the emergency department. Emerg Med Clin North Am. 2010 Aug. 28(3):663-82. [Medline].

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

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

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

  38. [Guideline] Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jun 11. 61 (23):e179-347. [Medline]. [Full Text].

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

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

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

  42. 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. 2004 Jan 8. 350(2):105-13. [Medline].

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

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

  45. Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016 Jun. 54 (5):345-64. [Medline].

  46. [Guideline] American Heart Association. Part 10: Special Circumstances of Resuscitation. Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Available at https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/. October 2010; Accessed: June 30, 2016.

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

  48. Chang AM, Walsh KM, Shofer FS, et al. Relationship between cocaine use and coronary artery disease in patients with symptoms consistent with an acute coronary syndrome. Acad Emerg Med. 2011 Jan. 18(1):1-9. [Medline].

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

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

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

  52. 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].

  53. Moreira M, Buchanan J, Heard K. Validation of a 6-hour observation period for cocaine body stuffers. Am J Emerg Med. 2011 Mar. 29(3):299-303. [Medline]. [Full Text].

  54. Brooks M. Anticonvulsant May Help Treat Cocaine Addiction. Medscape Medical News. Oct 28 2013. Available at http://www.medscape.com/viewarticle/813313. Accessed: Nov 5 2013.

  55. Johnson BA, Ait-Daoud N, Wang XQ, Penberthy JK, Javors MA, Seneviratne C, et al. Topiramate for the Treatment of Cocaine Addiction: A Randomized Clinical Trial. JAMA Psychiatry. 2013 Oct 16. [Medline].

  56. Martell BA, Orson FM, Poling J, et al. Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial. Arch Gen Psychiatry. 2009 Oct. 66(10):1116-23. [Medline].

  57. 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. 1995 Jun 29. 332(26):1753-7. [Medline].

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

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

 
Previous
Next
 
Patient transporting cocaine packets seen on KUB and lateral radiographs (mostly on left side). The patient was admitted, and a large number of packets was later obtained without procedural intervention or complication.
Patient transporting cocaine packets seen on KUB and lateral radiographs (mostly on left side). The patient was admitted, and a large number of packets was later obtained without procedural intervention or complication.
CT scan of patient transporting cocaine packets.
Schematics show the 3 types of action potentials in the right ventricle: endocardial (End), mid myocardial (M), and epicardial (Epi). A, Normal situation on V2 ECG generated by transmural voltage gradients during the depolarization and repolarization phases of the action potentials. B-E, Different alterations of the epicardial action potential that produce the ECGs changes observed in patients with Brugada syndrome. Adapted from Antzelevitch, 2005.
Three types of ST-segment elevation in Brugada syndrome, as shown in the precordial leads on ECG in the same patient at different times. Left panel shows a type 1 ECG pattern with pronounced elevation of the J point (arrow), a coved-type ST segment, and an inverted T wave in V1 and V2. The middle panel illustrates a type 2 pattern with a saddleback ST-segment elevated by >1 mm. The right panel shows a type 3 pattern in which the ST segment is elevated < 1 mm. According to a consensus report (Antzelevitch, 2005), the type 1 ECG pattern is diagnostic of Brugada syndrome. Modified from Wilde, 2002.
Table 1. Onset of Effects, Peak Effects, Duration of Euphoria, and Plasma Half-Life by Routes of Administration
Route Onset Peak Effect (min) Duration (min) Half-Life (min)
Inhalation 7 s 1-5 20 40-60
Intravenous 15 s 3-5 20-30 40-60
Nasal 3 min 15 45-90 60-90
Oral 10 min 60 60 60-90
Table 2. DAWN Data, 2011
Total ED Visits for Cocaine in US 505,224
White 185,748
Black 236,089
Hispanic 49,810
Other/2+ Race/Ethnicities 5086
Unknown 28,490
Table 3. Current Cocaine Use by Age: 2011
Age Range (y) Cocaine Use, Any Form, Past Month (Percentage of Same-age Population) Crack Cocaine Use, Past Month (Percentage of Same-age Population)
Total 1.5 million (0.6%) 354,000 (0.1%)
12-17 39,000 (0.2%) 8000 (<0.1%)
18-25 473,000 (1.4%) 29,000 (0.1%)
≥26 1.0 million (0.5%) 317,000 (0.2%)
Table 4. 2011 DAWN Data on Emergency Department Visits for Cocaine, by Age
Age, y Number of Visits
0-11 ...
12-17 5904
18-20 15,198
21-24 37,643
25-29 57,398
30-34 55,247
35-44 127,405
45-54 154,101
55-64 47,064
≥65 4887
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.