Cocaine toxicity

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Background

Cocaine chemical structure
  • Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin
  • A sympathomimetic stimulant derived from an alkaloid paste made from the leaves of the coca plant
  • Both a legitimate medical drug and a drug of abuse

Forms of Abuse

  • Cocaine can be smoked, snorted, injected or ingested
  • Smoked form is often in a free-base or crack form

Clinical Features

Differential Diagnosis

Sympathomimetics

Drugs of abuse

Evaluation

Work-Up

  • Glucose
  • Chemistry
  • ECG
  • Troponin
  • Total CK
  • LFT
  • Coags
  • Consider CT/LP if concern for ICH
  • Consider lactate/CTA if concern for bowel ischemia

Evaluation

  • Generally clinical and historical diagnosis
  • Utox is rarely helpful
    • Can be potentially positive up to 72hr post-ingestion
    • Often negative in acute ingestion
  • ECG

Detection

  • Unreliable in very acute intoxication[1]
  • Qualitative urine detection of cocaine metabolite benzoylecgonine at cut-off of 300 ng/ml
    • On average, shows up in urine 24-48 hrs after use
    • Up to 22 days in chronic users

Management

  1. Sedation[2]
    • Diazepam 5-10mg IV OR lorazepam 2mg IV q5min PRN agitation
    • Avoid haldol (lowers seizure threshold, contributes to dysrhythmias, hyperthermia)
  2. Cooling (if needed)
  3. Aspirin
  4. Hypertensive emergency
    • Benzos
    • Phentolamine 2.5-5mg IV (direct α-adrenergic antagonist, anti-hypertensive of choice) [3] OR nitroprusside 0.3mcg/kg/min
    • Beta-blockers contraindicated
      • May cause paradoxical hypertension

Dysrhythmias

  • Tachycardias usually respond to benzodiazepines
  • Wide complex tachycardia (deviation from ACLS)
    • Treat with bicarbonate 1-2 mEq IV bolus; titrate to pH 7.45-7.55
    • Consider lidocaine IV if refractory to NaHCO3 (controversial)

STEMI

  • Cardiac cath is safest option; consult (if possible) before using thrombolytics

Disposition

  • Patients who do not develop complications may be discharged to home
  • Patients demonstrating end organ dysfunction (e.g. CHF) should be admitted

Special Populations

  • Cocaine-associated chest pain
  • Levamisole toxicity (rash, neutropenia, vasculitis)
    • Up to 70% of US cocaine contaminated
  • Acute pulmonary toxicity from crack cocaine (Crack lung)
  • Body packing
    • Multiple packets of cocaine inserted in latex bags, ingested to cross borders
    • Each packet potentially toxic dose of cocaine (death likely if bag bursts)
    • Consider whole bowel irrigation, via NGT at 2L per hour
    • Endoscopy contraindicated (high % leakage/rupture of packets)
    • Surgical removal indicated for any evidence of cocaine toxicity
    • Do not discharge until all packets removed or 3 packet-free stools
    • Do not use oil based laxatives, they reduce the tensile strength of packets
  • Body stuffing
    • Ingestion of illicit drugs while pursued by law enforcement; usually small quantity
    • Consider activated charcoal, 1g/kg (up to 50g) PO q4hours for several doses
    • Consider whole bowel irrigation if develop toxicity
    • Consider discharge if do not develop toxicity after 4hr obs

Complications

Acute

Chronic

See Also

References

  1. McCord J, et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117: 1897-1907.
  2. McCord, J., Jneid, H., Hollander, J. E., de Lemos, J. A., Cercek, B., Hsue, P., Gibler, W. B., Ohman, E. M., Drew, B., Philippides, G. and Newby, L. K. (2008) ‘Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement From the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology’, Circulation, 117(14), pp. 1897–1907. doi: 10.1161/circulationaha.107.188950.
  3. Rosen's
  4. Forrester, J. M., Steele, A. W., Waldron, J. A. and Parsons, P. E. (1990) ‘Crack Lung: An Acute Pulmonary Syndrome with a Spectrum of Clinical and Histopathologic Findings’, American Review of Respiratory Disease, 142(2), pp. 462–467. doi: 10.1164/ajrccm/142.2.462.
  5. Ettinger, N. A. and Albin, R. J. (1989) ‘A review of the respiratory effects of smoking cocaine’, The American Journal of Medicine, 87(6), pp. 664–668. doi: 10.1016/s0002-9343(89)80401-2.