Cocaine Abuse & Overdose
Introduction
Cocaine is a popular illegal recreational drug used in Ireland and it is second only to opiates as the most common cause of drug related emergency department attendances in Ireland.
Cocaine produces a dose-dependent increase in heart rate and blood pressure accompanied by increased alertness, euphoria and decreased inhibition. Cocaine can cause vasospasm and enhanced thrombus formation in the coronary arteries leading to myocardial ischaemia
Toxicity can also occur in every other organ secondary to cocaine’s sympathomimetic, vasospastic and sodium channel blocking effects. The cardiovascular and neurological affects are usually the immediate concern in an ED settings
Clinical Features
Clinical manifestations vary widely depending upon the level of intoxication and organ system affected but may include;
Symptoms
CNS
anxiety, euphoria, paranoia, hallucinations, headache
CVS
Chest pain, palpitations, SOB
Musculoskeletal
localised/generalised muscle aches and pains
Respiratory
cough, SOB
Signs
CNS
Hyperthermia, psychomotor agitation, myoclonic movements, seizures,
CVS
tachycardia, hypertension, pulmonary oedema
Peripheral
sweating, tremor, mydriasis
Signs of complications
Complications
Cardiovascular
STEMI/NSTEMI, Coronary Vasospasm, Arrhythmias, QT prolongation, Aortic Dissection, Acute Pulm Oedema
Neurological
Seizures, Carotid Dissection, Intracerebral haemorrhage
Respiratory
Pneumothorax, Pneumomediastinum. “Crack Lung Syndrome” in crack smokers
Psych
paranoia, hallucinations, psychosis
GIT
Peptic Ulcer Disease, Ischaemic colitis
Musculoskeletal
Rhabdomyolysis, Compartment syndrome.
Differential Diagnosis
Psychomotor agitation is a common and important feature of many other overdose and disease states. Other conditions that should be considered include:
Hypoxia
Intracerebral haemorrhage
Hypoglycemia
Alcohol or Benzodiazepine withdrawal syndromes
Amphetamine Intoxication
Serotonin Syndrome
CNS Infections
Psychiatric Illness
Clinical Investigations
Should be guided by the clinical presentation.
Bedside
Venous Blood Gas
Urine Tox screen
Often utilised but of limited value in the acute clinical management
ECG
? ischaemia, ? Arrhythmia, ? conduction abnormalities such as QRS or QT prolongation
Laboratory
General Investigations
FBC, U&E, CRP, LFT – to assess for end organ dysfunction.
Creatine Kinase
if concerned for rhabdomyolysis
Troponin
if concerned for myocardial injury
Radiology
CXR
part of chest pain assessment. ? Pneumothorax, ? Pneumomediastinum
CT Brain
If concerned about bleed or stroke
CT Angiogram if concerned about dissection
Management and Disposition
Cocaine has a half-life of approximately one hour and there is no specific antidote. Management focuses on limiting its harmful effects and identifying and managing any complications.
Initial Resuscitation
Severe toxicity should be managed in resus
Assessment and concurrent management of Airway, Breathing and Circulation.
IVC and Fluids as clinically indicated
Symptomatic & Specific Treatment
Cardiovascular and CNS stimulation including seizures should be treated with benzodiazepines (IV if severe)
Chest pain or severe hypertension
Sublingual GTN or IV GTN infusion if concerned re acute pulmonary oedema, aortic dissection or critical hypertension
Hyperthermia refractory to BDZ may require active external cooling
Dispostion
Patients with severe psychomotor agitation, hyperthermia, or severe neurological or cardiovascular complications of cocaine toxicity may require admission to HDU/ICU environment
If after a period of observation their symptoms resolve with their acute intoxication, they are awake, alert, and ambulatory and their re-examination reveals no concerning findings, they may be discharged from the ED with advice regarding their drug use and supports available in the community
Patients with cocaine associate chest pain will require a period of monitoring and serial ECGs and cardiac enzymes. This can happen as an inpatient or in the ED if a Short Stay Unit is available
References
Hollander J. Cocaine Intoxication and Hypertension. Annals of Emergency Medicine. 2008;51(3):S18-S20.
Nelson, L et al. Cocaine: Acute intoxication. Uptodate.com
Tintinalli J. Tintinalli's Emergency Medicine. 9th ed. McGraw-Hill Education; 2019.
Murray L. Toxicology Handbook. 2nd ed. 2011
This blog was written by Dr David Hogan and was last updated in January 2021