High mortality rate with cocaine associated:

• Hyperthermia (worsening) portends imminent arrest: aggressive external cooling, sedation, and, if needed, intubation, to facilitate more invasive cooling measures.
• Delirium “Hyperactive delirium with severe agitation”.

– aggression, hyperactivity, extreme paranoia, hyperthermia, incoherent screaming, and excessive strength – needs aggressive sedation – restrain carefully supine/on side NOT face down (prone).

Other significant presentations – dysrhythmias, chest pain, headache/focal neurodeficit,

Consider mixed substances, either intentionally or unintentionally.

• E.g., IV heroin and cocaine = “speedballing” with initial signs of opioid toxicity but following the administration of naloxone, manifests signs of cocaine toxicity.
• Consider adulterants or “cutting agents”: caffeine, diltiazem, hydroxyzine, levamisole (agranulocytosis, vasculititis), Phenacetin.

Consider body packing or body stuffer when appropriate.

IF ANY CONCERN Call BC Drug and Poison Information Centre (BC DPIC)

24-Hour Line: 1-800-567-8911 or 604-682-5050.

(Telephone interpreting in over 150 languages available).

• Cocaine – derived from cocoa leaves; Crack cocaine (also called free base) is alkalinized cocaine and is heat stable and can be smoked unlike cocaine.
• Presentation varies based on individual tolerance and dose.
• Multiple mechanisms of toxicity:
  • Acute: blocks norepinephrine reuptake (adrenergic effects); blocks sodium/potassium channels (local anesthetic affects); and direct vessel damage.
  • Chronic: cardiac fibrosis, myocarditis, and necrosis.

Sympathomimetic Toxidrome:

• Diaphoretic
• Mydriasis
• Tachycardic
• Hypertensive
• Tachypneic
• Hyperthermic
• Agitated, psychosis, can hallucinate and,
• Seizures à focal – suspect intracerebral hemorrhage or infarction.

Common complications:

• Tachydysrhythmia – sinus tach; atrial fib; Torsade de Pointes, Ventricular tachycardia
• Severe hypertension
• Acute coronary syndrome
• Stroke
• Acute heart failure
• Acute renal failure
• Seizure
• Hyperthermia
• Rhabdomyolysis
• Neuropsychiatric: agitation, paranoia, mania, and severe delirium.

Uncommon complications:

• Paralysis from cocaine-associated vasospasm of an anterior spinal artery.
• “Crack lung” = fever, hemoptysis, hypoxia, ARDS, respiratory failure.
• Limb ischemia.
• Decreased LOC = intracerebral bleed/ischemia or co-ingestant of sedating drugs.

Investigations based on presentation:

• CBC, lytes, BS, BUN, Cr, LFT
• Troponin
• CK
• ECG

• Non-pharmacological, including surgical treatments.
• Preferred or recommended drugs and dosages.
• Treatments to avoid (i.e., often used but shown to be ineffective).

• The following are considerations to admit if not resolving:
  • Hyperthermia.
  • Rhabdomyolysis.
  • Other signs of end-organ damage.
  • Diagnostic or evolving ECGs suggesting ischemia or infarction.
  • Dysrhythmias other than sinus tachycardia.
  • Positive cardiac biomarkers and ongoing symptoms.
  • Congestive heart failure.
  • Passage/monitoring of patients presenting with body packing.
• Keep low threshold for pediatric patients even if sympathetic toxicity symptoms are mild.

• Contaminants change rapidly and vary by geographic region.
  • If the patient presentation is confusing, call poison control center.
• If hypotension and QRS prolongation do not improve with sodium bicarbonate, consider intravenous lipid emulsion therapy with a medical toxicologist.
• Consult surgery for body packers with symptomatic patients.
• Consult obstetrics if an obstetric patient is found as developmental abnormalities of fetus/neonate may occur.

– Counselling and substance use support.

• Considerations for safe discharge
  • Patients with relatively mild sympathomimetic presentation that resolve spontaneously.
  • Patients who show no signs of end-organ damage.
  • Patients with no concerning history or presentation elements.
  • Patients with good response to sedation therapy.
  • Discharge after vital signs and mental status remain normal after 4-6 hours.
• Body packers need to have passed all packets and remain asymptomatic with normal vitals for 6-12 hours.
• For patients with chest pain
  • Some centers recommend up to 12 hours of monitoring but more are moving to shorter durations.
  • Application of an abbreviated cardiac enzyme protocol (at 0, 2, 4, and 8 hours) with continuous cardiac monitoring can be considered.
  • Patients who are pain free with no abnormalities on ECG can be discharged if a single cardiac marker after 8 hours of the onset of chest pain is normal.
• For all patients, provide a referral for detoxification.

1. Lewis SN, Mary AH, Neal AL, et al. Goldfrank’s Toxicologic Emergencies. 11th edition. McGraw-Hill Education; 2019.

   
   

2. Chary MA, Erickson TB. Cocaine and Other Sympathomimetics in Rosen’s Emergency Medicine. 10th edition. Elsevier; 2023.

   
   

3. Zimmerman LJ. Cocaine Intoxication. Critical Care Clinics; 2012.