View source for Cocaine toxicity

==Background==
[[File:Kokain_-_Cocaine.svg.png |thumb|Cocaine chemical structure]]
[[File:CocaineHydrochloridePowder cropped.jpg|thumb|A pile of cocaine hydrochloride]]
[[File:Rocks of crack cocaine.jpg|thumb|"Rocks" of crack cocaine]]
*Works via blockade of presynaptic reuptake of norepinephrine, dopamine, and serotonin
*A [[Sympathomimetic toxicity|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==
[[File:Side effects of chronic use of Cocaine.png|thumb|Side effects of chronic cocaine use]]
*Sympathomimetic toxidrome:
**Tachycardia, diaphoresis, mydriasis, hypertension, hyperthermia, agitation
*[[Cocaine-associated chest pain]]
*"[[Crack lung]]"
*"Crack dancing" (choreoathetoid movement disorder)
*May be associated with end organ damage:
**[[Dysrhythmias]]
**[[Aortic dissection]]
**[[Pulmonary edema]]
**[[MI]]
**[[Encephalopathy]]
**[[ICH]]
**[[CVA]]
**Intestinal ischemia
**Renal failure ([[rhabdomyolysis]])

==Differential Diagnosis==
{{Sympathomimetic types}}
{{Drugs of abuse types}}

==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
**See [[Toxidromes]]
*[[Urine toxicology screen]] is rarely helpful
**Can be potentially positive up to 72hr post-ingestion
**Often negative in acute ingestion
*[[ECG]]
**May show QRS, [[QT prolongation]]

===Detection===
*Unreliable in very acute intoxication<ref>McCord J, et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117: 1897-1907.</ref>
*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==
#Sedation<ref>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.</ref>
#*[[Diazepam]] 5-10mg IV OR lorazepam 2mg IV q5min PRN agitation
#*Avoid [[haldol]] if patient has abnormal vital signs (lowers seizure threshold, contributes to dysrhythmias, hyperthermia) 
#Cooling (if needed)
#Aspirin
#Hypertensive emergency
#*[[Benzos]]
#*Phentolamine 2.5-5mg IV (direct α-adrenergic antagonist, anti-hypertensive of choice) <ref>Rosen's</ref> OR nitroprusside 0.3mcg/kg/min
#*[[Beta-blockers]] contraindicated
#**May cause paradoxical hypertension
#IV crystalloid replacement (most patients have salt and water depletion)

===[[Dysrhythmias]]===
*Tachycardias usually respond to [[benzodiazepines]]
*Wide complex tachycardia (deviation from ACLS)
**Treat with bicarbonate 1-2 mEq/kg IV bolus; titrate to pH 7.45-7.55
***Cocaine has sodium-channel blockade effect (similar to [[TCA]] toxicity)
**Consider lidocaine IV if refractory to NaHCO3 (controversial)

===[[STEMI]]===
*Cardiac cath is safest option; consult (if possible) before using thrombolytics


==Medication Dosing==
{{MedicationDose
| drug = Diazepam
| dose = 5-10mg IV q5min PRN agitation
| route = IV
| context = First-line for agitation, seizures, and sympathetic excess
| indication = Cocaine toxicity
| population = Adult
}}
{{MedicationDose
| drug = Phentolamine
| dose = 2.5-5mg IV
| route = IV
| context = Direct alpha-antagonist for refractory hypertension
| indication = Cocaine toxicity
| population = Adult
| notes = Anti-hypertensive of choice per Rosen's; avoid beta-blockers
}}

==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===
*[[Cocaine-associated chest pain]]
*Sympathomimetic qualities
**Tachycardia
**Fever
**Agitation
**Diaphoresis
*Pulmonary Complications:
**"[[Crack lung]]"<ref>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.</ref>
**Diffuse alveolar hemorrhage<ref>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.</ref>
**[[ARDS]]
**Acute eosinophilic pneumonia
**[[Pneumothorax]]
**[[Pneumomediastinum]]
**Thermal epiglottitis - hot cocaine
*Other Complications
**[[Rhabdomyolysis]]
**[[glaucoma|Angle closure glaucoma]]

===Chronic===
*Atherosclerosis
*Cardiomyopathy
*Nasal Septum damage
*Up to 70% of US cocaine tainted with [[levamisole]], potentially leading to [[neutropenia]], [[vasculitis]]

==See Also==
*[[Toxicology (Main)]]
*[[Cocaine-associated chest pain]]
*[[Acute pulmonary toxicity from crack cocaine]]
*[[Cocaine Withdrawal]]
*[[Cocaine]]
*[[Levamisole toxicity]]

==References==
<references/>

[[Category:Toxicology]]