Cocaine Toxicity Differential Diagnoses

1. Centers for Disease Control and Prevention. Annual Surveillance Report of Drug-Related Risks and Outcomes: United States, 2019. Available at https://www.cdc.gov/drugoverdose/pdf/pubs/2019-cdc-drug-surveillance-report.pdf. November 1, 2019; Accessed: January 21, 2023.

2. Havakuk O, Rezkalla SH, Kloner RA. The Cardiovascular Effects of Cocaine. J Am Coll Cardiol. 2017 Jul 4. 70 (1):101-113. [QxMD MEDLINE Link].

3. 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.

4. Drug Enforcement Administration. 2020 National Drug Threat Assessment. Available at https://www.dea.gov/sites/default/files/2021-02/DIR-008-21%202020%20National%20Drug%20Threat%20Assessment_WEB.pdf. March 2021; Accessed: January 21, 2023.

5. United Nations Office on Drugs and Crime (UNODC). Drug Market Trends: Cocaine Amphetamine-type Stimulants and New Psychoactive Substances. World Drug Report 2022: Booklet 4. United Nations publication, Sales No. 22.XI.8; June 2022. [Full Text].

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

7. 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. [QxMD MEDLINE Link].

8. 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. [QxMD MEDLINE Link].

9. Brunt TM, van den Berg J, Pennings E, Venhuis B. Adverse effects of levamisole in cocaine users: a review and risk assessment. Arch Toxicol. 2017 Jun. 91 (6):2303-2313. [QxMD MEDLINE Link].

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

11. 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. [QxMD MEDLINE Link].

12. 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. [QxMD MEDLINE Link].

13. 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. [QxMD MEDLINE Link].

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

15. 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. [QxMD MEDLINE Link].

16. 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. [QxMD MEDLINE Link].

17. 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. [QxMD MEDLINE Link].

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

19. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Rivers LJ, Feldman R, et al. 2021 Annual Report of the National Poison Data System(©) (NPDS) from America's Poison Centers: 39th Annual Report. Clin Toxicol (Phila). 2022 Dec. 60 (12):1381-1643. [QxMD MEDLINE Link]. [Full Text].

20. 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].

21. 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. [QxMD MEDLINE Link].

22. 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].

23. McCall Jones C, Baldwin GT, Compton WM. Recent Increases in Cocaine-Related Overdose Deaths and the Role of Opioids. Am J Public Health. 2017 Mar. 107 (3):430-432. [QxMD MEDLINE Link].

24. Xie Y, Pope BA, Hunter AJ. Cotton Fever: Does the Patient Know Best?. J Gen Intern Med. 2016 Apr. 31 (4):442-4. [QxMD MEDLINE Link]. [Full Text].

25. 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. [QxMD MEDLINE Link].

26. Yarnell SC. Cocaine Abuse in Later Life: A Case Series and Review of the Literature. Prim Care Companion CNS Disord. 2015. 17 (2):[QxMD MEDLINE Link]. [Full Text].

27. 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. [QxMD MEDLINE Link].

28. 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. [QxMD MEDLINE Link].

29. Dos Santos JF, de Melo Bastos Cavalcante C, Barbosa FT, Gitaí DLG, Duzzioni M, Tilelli CQ, et al. Maternal, fetal and neonatal consequences associated with the use of crack cocaine during the gestational period: a systematic review and meta-analysis. Arch Gynecol Obstet. 2018 Jun 27. [QxMD MEDLINE Link].

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

31. Wiener SE, Sutijono D, Moon CH, Subramanian RA, Calaycay J, Rushbrook JI, et al. Patients with detectable cocaethylene are more likely to require intensive care unit admission after trauma. Am J Emerg Med. 2010 Nov. 28 (9):1051-5. [QxMD MEDLINE Link].

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

33. 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. [QxMD MEDLINE Link].

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

35. Franklin SM, Thihalolipavan S, Fontaine JM. Sinus Bradycardia in Habitual Cocaine Users. Am J Cardiol. 2017 May 15. 119 (10):1611-1615. [QxMD MEDLINE Link].

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

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

38. 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. [QxMD MEDLINE Link].

39. 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. [QxMD MEDLINE Link].

40. Prosser JM, Hoffman RS. Cocaine. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds, eds. Goldfrank's Toxicologic Emergencies. 10th ed. New York: McGraw-Hill Education; 2015.

41. 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. [QxMD MEDLINE Link].

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

43. Prosser JM, Perrone J. Cocaine and Amphetamines. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. NY: McGraw-Hill Education; 2016. 1256-59.

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

45. [Guideline] American Heart Association. 2020 American Heart Association Guidelines for CPR and ECC. Available at https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines. Accessed: January 21, 2023.

46. [Guideline] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23. 64 (24):e139-228. [QxMD MEDLINE Link]. [Full Text].

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

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

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

50. 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. [QxMD MEDLINE Link].

51. 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. [QxMD MEDLINE Link].

52. Derlet RW. More on lidocaine use in cocaine toxicity. J Emerg Nurs. 1998 Aug. 24(4):303. [QxMD MEDLINE Link].

53. 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. [QxMD MEDLINE Link].

54. Thomas JJ, Brady WJ. Acute Coronary Syndrome. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018. 891-928.

55. 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. [QxMD MEDLINE Link].

56. Zun LS, Nordstrom K. Anxiety Disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018.

57. 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. [QxMD MEDLINE Link].

58. 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.

59. Minns AB, Clark RF. Substance Abuse. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018. 1823-28.

60. 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. [QxMD MEDLINE Link].

61. 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. [QxMD MEDLINE Link]. [Full Text].

62. Brooks M. Anticonvulsant May Help Treat Cocaine Addiction. Medscape Medical News. Available at http://www.medscape.com/viewarticle/813313. Oct 28 2013; Accessed: January 21, 2023.

63. 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. [QxMD MEDLINE Link].

64. 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. [QxMD MEDLINE Link].

Lynn Barkley Burnett, MD, EdD, JD Medical Advisor, Fresno County Sheriff's Office; Attending Consultant-in-Chief and Chairman, Medical Ethics, Community Medical Centers; Instructor in Emergency Medicine, Campbell University School of Osteopathic Medicine; Core Graduate Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program; Associate Faculty, University of Arizona College of Medicine-Phoenix

Lynn Barkley Burnett, MD, EdD, JD 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 & Ethics, American Stroke Association, The Society of Federal Health Professionals (AMSUS), Christian Medical and Dental Associations, 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, 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, World Association for Disaster and Emergency Medicine

Disclosure: Nothing to disclose.

Carlos J Roldan, MD, FAAEM, FACEP Professor of Emergency Medicine, Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center at Houston; Associate Professor of Pain Medicine, Department of Pain Medicine, 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.

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.

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.

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

• Print this section
• Print the entire contents of
• Print the entire contents of article