Cocaine Intoxication: Treatment

Advanced, Clinical Subspecialties

Cocaine is an ester local anesthetic derived from coca leaves that is readily absorbed via mucosal surfaces in oral, nasal, or pulmonary alveoli. Today, it is most often used as a drug of abuse but was originally used in eye surgery as a local anesthetic. Cocaine acts as an indirect sympathomimetic by inhibiting norepinephrine reuptake at adrenergic nerve terminals potentiating adrenergic stimulation and can cause euphoria via inhibition of serotonin reuptake in the CNS. Acute overdose symptoms include tremors, restlessness, convulsions, psychomotor agitation, headache, hyperthermia, arrhythmias, cardiac arrest, emesis, SOB, and pleuritic chest pain. 

Cocaine Intoxication Management

Airway and breathing : Respiratory drive is usually maintained but supplemental oxygen may be necessary. If RSI is needed for intubation the use of succinylcholine is relatively contraindicated as cocaine is also metabolized by plasma cholinesterases and co-administration can prolong the effects of cocaine and paralysis of succinylcholine. 

Cardiovascular : Cardiovascular effects are centrally mediated via sympathetic stimulation and, therefore, benzodiazepines are first-line therapy for cardiovascular effects of acute intoxication. Refractory cocaine-induced hypertension can be treated with alpha-adrenergic blockers (phentolamine) or vasodilators without beta blocking effects (nitroglycerin and nitroprusside). Ventricular ectopy and other cocaine-induced arrhythmias stem from increased adrenergic stimulation and have been treated with adrenergic antagonists and calcium channel blockers. 

Psychomotor agitation : Agitation, restlessness, and psychomotor agitation are hallmarks of intoxication and can also be treated with benzodiazepines (often diazepam) with appropriate monitoring for respiratory depression and hypotension. IM lorazepam and midazolam can be used if IV access cannot be obtained.

Hyperthermia :  Rapid cooling to a body temperature <102°F, ideally in <30 minutes, with immersion in ice, gastric lavage with cold, cooled IV fluids

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2019

Year asked

Author
Cameron Sumner, MD