Medication Summary
The general objectives of pharmacotherapeutic intervention in cocaine toxicity are to reduce the central nervous system and cardiovascular effects of the drug by using benzodiazepines initially and then to control clinically significant tachycardia and hypertension while simultaneously attempting to limit deleterious drug interactions.
In a cardiac arrest, vasopressin may offer considerable advantage over epinephrine.
Some patients who abuse cocaine have enhanced sensitivity to benzodiazepines despite a significantly decreased plasma concentration. Be alert to the extreme sedative effects that have been noted after the administration of lorazepam to some patients who used cocaine.
Nitroglycerin or nitroprusside may be needed to treat severe hypertension. For both of these drugs, an infusion system that ensures a precise rate of flow is needed. Closely monitor the patient's vital signs when vasoactive and antihypertensive medications are used. When vasoactive agents are discontinued, taper them slowly.
Hypotension may compound the patient's status; if present, norepinephrine may be required.
Hypoglycemia is always a possibility in patients presenting with neuropsychiatric syndromes. If bedside glucose results confirm the need, administer thiamine and glucose. Thiamine should be administered before dextrose in patients with signs of Wernicke encephalopathy.
Benzodiazepines
Class Summary
By increasing the action of GABA, a major inhibitory neurotransmitter in the brain, these drugs may depress all levels of the CNS, including the limbic system and reticular formation.
Lorazepam (Ativan)
DOC for status epilepticus because it persists in CNS longer than diazepam. Rate of injection should not exceed 2 mg/min. May be administered IM if unable to obtain vascular access.
Midazolam (Versed)
Alternative for termination of refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects; therefore, clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors as diazepam. May be administered IM if unable to obtain vascular access.
Diazepam (Valium)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing GABA activity. Third-line agent for agitation or seizures because of shortened duration of anticonvulsive effects and accumulation of active metabolites that may prolong sedation. Diazepam should not be administered intramuscularly, because absorption is unreliable.
Cardiovascular agents
Class Summary
Alkalinization may benefit cardiac conduction if a wide QRS is noted. Other treatment for cardiac arrest, dysrhythmias, or acute hypertension may also be required.
Sodium bicarbonate (Neut)
Possibly useful for alkalization of urine in patients with rhabdomyolysis. Appropriate for dysrhythmias from direct toxic effects of cocaine (ie, QRS greater than 100 ms due to sodium channel blockade).
Lidocaine (Anestacon, Dilocaine, Xylocaine, Zilactin-L, Dermaflex)
Class IB antidysrhythmic that increases electrical stimulation threshold of ventricle, suppresses automaticity, and slows conduction velocity through ischemic tissue. Indicated for cocaine-induced VF and VT.
Esmolol (Brevibloc)
Beta-blockers are generally contraindicated in cocaine toxicity. Some recommend to "save use" together with a vasodilator, only to manage life-threatening hypertension, tachycardia, and aortic dissection unresponsive to other therapeutic interventions. Short half-life of 8 min allows for titration to desired effect and quick discontinuation if needed.
NTG (Deponit, Nitrostat)
Used to treat acute hypertension and cardiac chest pain. Relaxes vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production, decreasing BP. Selection of NTG or sodium nitroprusside based on clinician's preference.
Phentolamine (Regitine)
Alpha1- and alpha2-adrenergic blocking agent that blocks circulating epinephrine and norepinephrine action, reducing hypertension and coronary vasoconstriction due to catecholamine effects on alpha-receptors.
Nitroprusside (Nitropress)
Used to treat acute hypertension. Produces vasodilation and increases cardiac inotropic activity. At high dosages, may exacerbate myocardial ischemia by increasing heart rate. Selection of NTG or sodium nitroprusside based on clinician's preference.
Norepinephrine (Levophed)
Stimulates alpha and beta1-adrenergic receptors with alpha-adrenergic predominance which increases cardiac muscle contractility, heart rate, and vasoconstriction; results are increased systemic BP and coronary blood flow. As a vasopressor, useful in hypotension not responsive to IV fluids alone.
Epinephrine
Useful for achieving return of spontaneous circulation, but may not improve the chances of recovery with a good neurologic outcome. Increases coronary perfusion pressure.
Vasopressin
May improve vital organ blood flow, cerebral oxygen delivery, ability to be resuscitated, and neurologic recovery.
GI agents
Class Summary
Whole-bowel irrigation with polyethylene glycol promotes the passage of cocaine packets through the GI tract. Activated charcoal may be empirically used to minimize systemic absorption of the toxin.
Polyethylene glycol (Colovage, CoLyte, GoLYTELY, NuLytely)
Laxative with strong electrolyte and osmotic effects. Cathartic actions in GI tract. May be indicated in treatment of cocaine ingestion in people who carry cocaine packages in their body. Must administer after activated charcoal. Liquid reconstituted per package instructions.
Activated charcoal (Liqui-Char)
Emergency treatment for absorption of drugs or chemicals. Network of pores adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water. Some formulations also contain a cathartic.
For maximum effect, administer within 30 min of poison ingestion. Although value of multiple doses to treat acute drug ingestion not established, in some carefully considered situations, dose may be repeated at half original dose q2-6h until symptoms of toxicity subside, serum drug concentrations return to reference range (if initially elevated) or drug packets eliminated. Repeat doses should not contain cathartic.
Nutrients
Class Summary
Thiamine should be administered before glucose to prevent Wernicke encephalopathy.
Thiamine (Vitamin B1)
Administered to prevent Wernicke encephalopathy. If the patient is already showing signs of Wernicke encephalopathy, thiamine should be administered before glucose.
Dextrose (D-glucose)
Monosaccharide absorbed from intestine and distributed, stored, and used by tissues. Parenteral injection used in patients unable to sustain adequate oral intake. Direct oral absorption rapidly increases blood glucose concentrations. Effective in small doses and no evidence suggests toxicity. Concentrated infusions provide increased amounts of glucose and increased caloric intake in small volume of fluid.
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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.
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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.
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CT scan of patient transporting cocaine packets.
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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.
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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.
Tables
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 |
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 |
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 |
1.9 million (0.7%) |
432,000 (0.2%) |
12-17 |
28,000 (0.2%) |
3000 (< 0.1%) |
18-25 |
552,000 (1.4%) |
15,000 (< 0.1%) |
≥26 |
1.3 million (0.5%) |
414,000 (0.2%) |
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 |
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