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Cocaine toxicity
From WikEM
Contents
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
- Cocaine-associated chest pain
- May be associated with end organ damage:
- Dysrhythmias
- Aortic dissection
- Pulmonary edema
- MI
- Encephalopathy
- ICH
- CVA
- Intestinal ischemia
- Renal failure (rhabdomyolysis)
Differential Diagnosis
Sympathomimetics
Drugs of abuse
- Cocaine
- Ecstasy
- Marijuana
- Amphetamines
- Alcohol
- Synthetic cannabinoids
- Bath salts
- Heroin
- 25C-NBOMe
- Inhalant abuse
- Gamma hydroxybutyrate (GHB)
- Phencyclidine (PCP)
- Psilocybin (magic mushrooms)
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
- Utox 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 alpha-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
- 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
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.
