Cocaine toxicity: Difference between revisions
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==Background== | ==Background== | ||
[[File:Kokain_-_Cocaine.svg.png |thumb|Cocaine chemical structure]] | [[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 | *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 | *A [[Sympathomimetic toxicity|sympathomimetic]] stimulant derived from an alkaloid paste made from the leaves of the coca plant | ||
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==Clinical Features== | ==Clinical Features== | ||
[[File:Side effects of chronic use of Cocaine.png|thumb|Side effects of chronic cocaine use]] | |||
*Sympathomimetic toxidrome: | *Sympathomimetic toxidrome: | ||
**Tachycardia, diaphoresis, mydriasis, hypertension, hyperthermia | **Tachycardia, diaphoresis, mydriasis, hypertension, hyperthermia, agitation | ||
*[[Cocaine-associated chest pain]] | |||
*"[[Crack lung]]" | |||
*"Crack dancing" (choreoathetoid movement disorder) | |||
*May be associated with end organ damage: | *May be associated with end organ damage: | ||
**[[Dysrhythmias]] | **[[Dysrhythmias]] | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Sympathomimetic types}} | {{Sympathomimetic types}} | ||
{{Drugs of abuse types}} | |||
==Evaluation== | ==Evaluation== | ||
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*Chemistry | *Chemistry | ||
*[[ECG]] | *[[ECG]] | ||
*Troponin | *[[Troponin]] | ||
*Total CK | *Total CK | ||
*LFT | *LFT | ||
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*Generally clinical and historical diagnosis | *Generally clinical and historical diagnosis | ||
**See [[Toxidromes]] | **See [[Toxidromes]] | ||
* | *[[Urine toxicology screen]] is rarely helpful | ||
**Can be potentially positive up to 72hr post-ingestion | **Can be potentially positive up to 72hr post-ingestion | ||
**Often negative in acute ingestion | **Often negative in acute ingestion | ||
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#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> | #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 | #*[[Diazepam]] 5-10mg IV OR lorazepam 2mg IV q5min PRN agitation | ||
#*Avoid [[haldol]] (lowers seizure threshold, contributes to dysrhythmias, hyperthermia) | #*Avoid [[haldol]] if patient has abnormal vital signs (lowers seizure threshold, contributes to dysrhythmias, hyperthermia) | ||
#Cooling (if needed) | #Cooling (if needed) | ||
#Aspirin | #Aspirin | ||
#Hypertensive emergency | #Hypertensive emergency | ||
#*[[Benzos]] | #*[[Benzos]] | ||
#*Phentolamine 2.5-5mg IV (direct | #*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 | #*[[Beta-blockers]] contraindicated | ||
#**May cause paradoxical hypertension | #**May cause paradoxical hypertension | ||
#IV crystalloid replacement (most patients have salt and water depletion) | |||
===[[Dysrhythmias]]=== | ===[[Dysrhythmias]]=== | ||
*Tachycardias usually respond to | *Tachycardias usually respond to [[benzodiazepines]] | ||
*Wide complex tachycardia (deviation from ACLS) | *Wide complex tachycardia (deviation from ACLS) | ||
**Treat with bicarbonate 1-2 mEq IV bolus; titrate to pH 7.45-7.55 | **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) | **Consider lidocaine IV if refractory to NaHCO3 (controversial) | ||
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==Disposition== | ==Disposition== | ||
*Patients who do not develop complications may be discharged to home | *Patients who do not develop complications may be discharged to home | ||
*Patients demonstrating end organ dysfunction (CHF | *Patients demonstrating end organ dysfunction (e.g. CHF) should be admitted | ||
==Special Populations== | ==Special Populations== | ||
*Body | *[[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 | **Multiple packets of cocaine inserted in latex bags, ingested to cross borders | ||
**Each packet potentially toxic dose of cocaine (death likely if bag bursts) | **Each packet potentially toxic dose of cocaine (death likely if bag bursts) | ||
**Consider whole bowel irrigation | **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 | **Surgical removal indicated for any evidence of cocaine toxicity | ||
**Do not discharge until all packets removed or 3 packet-free stools | **Do not discharge until all packets removed or 3 packet-free stools | ||
*Body | **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 | **Ingestion of illicit drugs while pursued by law enforcement; usually small quantity | ||
**Consider activated charcoal | **Consider [[activated charcoal]], 1g/kg (up to 50g) PO q4hours for several doses | ||
**Consider whole bowel irrigation if develop toxicity | **Consider whole bowel irrigation if develop toxicity | ||
**Consider discharge if do not develop toxicity after 4hr obs | **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== | ==See Also== | ||
*[[Toxicology (Main)]] | *[[Toxicology (Main)]] | ||
*[[Cocaine-associated chest pain]] | *[[Cocaine-associated chest pain]] | ||
*[[Acute pulmonary toxicity from crack cocaine]] | |||
*[[Cocaine Withdrawal]] | *[[Cocaine Withdrawal]] | ||
*[[Cocaine]] | *[[Cocaine]] | ||
*[[Levamisole toxicity]] | |||
==References== | ==References== |
Latest revision as of 01:47, 11 February 2021
Background
- 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
- 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
Sympathomimetics
- Cocaine
- Amphetamines
- Synthetic cathinones (khat)
- Ketamine
- Ecstasy (MDMA)
- Synthetic cannabinoids
- Bath salts
Drugs of abuse
- 25C-NBOMe
- Alcohol
- Amphetamines
- Bath salts
- Cocaine
- Ecstasy
- Gamma hydroxybutyrate (GHB)
- Heroin
- Inhalant abuse
- Hydrocarbon toxicity
- Difluoroethane (electronics duster)
- Marijuana
- Kratom
- Phencyclidine (PCP)
- Psilocybin ("magic mushrooms")
- Synthetic cannabinoids
- Chloral hydrate
- Body packing
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[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
- Sedation[2]
- Cooling (if needed)
- Aspirin
- 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
- 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)
- Treat with bicarbonate 1-2 mEq/kg IV bolus; titrate to pH 7.45-7.55
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
- Cocaine-associated chest pain
- Sympathomimetic qualities
- Tachycardia
- Fever
- Agitation
- Diaphoresis
- Pulmonary Complications:
- "Crack lung"[4]
- Diffuse alveolar hemorrhage[5]
- ARDS
- Acute eosinophilic pneumonia
- Pneumothorax
- Pneumomediastinum
- Thermal epiglottitis - hot cocaine
- Other Complications
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
- ↑ McCord J, et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117: 1897-1907.
- ↑ 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.
- ↑ Rosen's
- ↑ 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.
- ↑ 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.