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Cocaine Poisoning, Emergency Medicine

Basics

Description

- Respiratory: - Tachypnea - Pleuritic chest pain: - Pneumomediastinum - Pneumothorax - Bronchitis - Pulmonary infarction

- Abdominal radiograph: - For body packers/stuffers - Usually produces negative result for stuffers because drug is loosely packed in cellophane - Positive for packers because drug is densely packed and usually radiopaque

- CT brain scan: - For altered mental status or severe headache - Detects cerebral ischemia or hemorrhage

- Cardiac chest pain: - Aspirin - Nitrates - Oxygen - Opiates - Avoid β-blockers because of unopposed ╬▒-stimulation - Angiography/angioplasty/thrombolysis for acute myocardial infarction

  • Sympathomimetic
  • Inhibits neurotransmitter reuptake at the nerve terminal
  • Metabolism:Hepatic degradationNonenzymatic hydrolysisCholinesterase metabolism

Etiology

  • IV, nasal, oral administration of cocaine
  • Oral ingestion:Body stuffers:Ingest hastily wrapped packets in attempt to evade police.Body packers:Ingest cocaine packets to smuggle the drug using couriers' oral, rectal, and vaginal cavities.Cocaine is wrapped carefully in packets containing large amounts of drug.

Diagnosis

Signs and Symptoms

  • Sympathomimetic toxidrome
  • Cardiovascular:HTNTachycardiaChest pain (angina)
  • Respiratory:TachypneaPleuritic chest pain:PneumomediastinumPneumothoraxBronchitisPulmonary infarctionCough
  • CNS:AgitationTremulousnessComaSeizuresStroke
  • Miscellaneous:Hyperthermia (poor prognosis)Limb ischemia (inadvertent intra-arterial injection)Corneal ulcerations (heavy crack smokers):Owing to local chemical and thermal irritation that disrupts corneal epitheliumRhabdomyolysis

History

For body packers and stuffers: á

  • Time since ingestion
  • Route of ingestion (oral, rectal, vaginal)
  • Number of packets ingested
  • Material and method of packing

Physical Exam

Sympathomimetic toxidrome: á

  • HTN
  • Tachycardia
  • Tachypnea
  • Hyperthermia
  • Diaphoresis
  • Mydriasis
  • Neuromuscular hyperactivity

Essential Workup

  • Recognition of the sympathomimetic toxidrome caused by cocaine:Distinguish from anticholinergic toxidrome.
  • Toxidrome recognition:Sympathomimetic:Heart rate (tachycardia)BP (increased)Moist skinBowel sounds presentTemperature (increased)No urinary retentionAnticholinergic:Heart rate (tachycardia)BP (increased)Dry skinBowel sounds diminishedTemperature (increased)Urinary retention present

Diagnosis Tests & Interpretation

Lab

  • CBC
  • Electrolytes, BUN, creatinine, glucose
  • Urinalysis dip for myoglobin
  • Cardiac enzymes (troponin, creatine phosphokinase [CPK]) for:Anginal chest painAbnormal results on ECG
  • CPK for evidence of myoglobinuria
  • Toxicology screen

Imaging

  • ECG:For anginal chest painConsider possibility of myocardial infarction with cocaine-related chest pain.
  • CXR:For chest pain or shortness of breathCheck for pneumomediastinum, pneumothorax, aortic rupture.
  • Abdominal radiograph:For body packers/stuffersUsually produces negative result for stuffers because drug is loosely packed in cellophanePositive for packers because drug is densely packed and usually radiopaque
  • CT of the abdomen with contrast:When unreliable history of body packers/stuffers and nothing visualized on abdominal frontal radiograph
  • CT brain scan:For altered mental status or severe headacheDetects cerebral ischemia or hemorrhage

Differential Diagnosis

Other agents with sympathomimetic effects á

  • Theophylline
  • Caffeine
  • Amphetamines
  • Albuterol
  • Tricyclic antidepressants
  • Antihistamines
  • Phencyclidine (PCP)
  • Thyrotoxicosis
  • Neuroleptic malignant syndrome
  • Hallucinogens

Treatment

Pre-Hospital

  • Establish IV access
  • Cardiac monitor:Chest pain may be ischemic.Benzodiazepine therapy to control agitation
  • When drug is used as a "speedball"Ł (combination of heroin and cocaine), administer naloxone in increments to reverse coma.

Initial Stabilization/Therapy

  • ABCs
  • Establish IV access.
  • Establish cardiac monitor.
  • Provide therapy with naloxone (Narcan), thiamine, dextrose (or Accu-Check) for altered mental status

Ed Treatment/Procedures

  • Supportive care for mildly symptomatic patients
  • Benzodiazepines:For agitation and tremorInitial agents for hypertension and tachycardia
  • Cooling measures for hyperthermia:Evaporative-convective method
  • Treat rhabdomyolysis:Hydrate with 0.9% NSAlkalinization with IV bicarbonate in severe cases
  • Cardiac chest pain:AspirinNitratesOxygenOpiatesAvoid β-blockers because of unopposed ╬▒-stimulationAngiography/angioplasty/thrombolysis for acute myocardial infarction
  • HTN/tachycardia:Benzodiazepine initial agentUse ╬▒-blocking agent (phentolamine) as sole agent or combine with β-blocker (propranolol, esmolol) if unresponsive to benzodiazepine.Use labetalol cautiously (does not have equal ╬▒- and β-blocking properties).IV nitroglycerin/nitroprusside for severe unresponsive hypertension
  • Body packer/stuffers:Treat asymptomatic or minimally symptomatic body packers and body stuffers:Single-dose activated charcoal is appropriate for asymptomatic or minimally symptomatic body stuffersWhole-bowel irrigation with polyethylene glycol electrolyte lavage solution (efficacy unknown)Consult with surgeons for symptomatic body packers and stuffers.If toxicity is not easily managed with previously suggested pharmacologic therapy, remove the drug packets intraoperatively.

Medication

First Line

  • Diazepam: 5 mg incremental doses IV
  • Lorazepam: 2 mg incremental doses IV

Second Line

  • Activated charcoal slurry: 1-2 g/kg up to 90 g PO
  • Dextrose: D50W 1 ampule (50 mL or 25 g) (peds: D25W 2-4 mL/kg) IV
  • Esmolol: 50-200 ╬╝g/kg/min IV infusion titrated to effect
  • Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg up to 2 mg) IV or IM initial dose
  • Nitroglycerin: 10-100 ╬╝g/min IV infusion
  • Nitroprusside: 0.3 ╬╝g/kg/min IV (titrate to effect up to 10 ╬╝g/kg/min)
  • Phentolamine: 5 mg IV q15-24min (titrate to clinical effect)
  • Polyethylene glycol (GoLYTELY): 1-2 L PO/hr until packet passage (efficacy controversial)

Follow-Up

Disposition

Admission Criteria

  • Altered mental status
  • Abnormal vital signs: Heart rate >100 bpm, diastolic BP >120 mm Hg, or hypotension
  • Hyperthermia
  • Cocaine-induced myocardial ischemia
  • Body stuffers and body packers
  • ICU admission for moderate to severe toxicity

Discharge Criteria

  • Mental status and vital signs normal after 6 hr of observation
  • Body packers or stuffers with confirmed expulsion of packets and no clinical signs of toxicity
  • Stuffers may be discharged if uncomplicated packets were ingested and if asymptomatic for 12-24 hr.

Pearls and Pitfalls

  • Benzodiazepines are the 1st-line treatment for the sympathomimetic toxidrome from cocaine.
  • Avoid β-blockers in the hyperdynamic cocaine intoxicated patient.
  • Consider a broad differential in cocaine-associated chest pain.
  • An abdominal flat plate radiograph will be of some value in a body packer, but of no value in imaging packets in a body stuffer.

Additional Reading

  • Hoffman áRS. Cocaine. In: Goldfrank áLR, ed. Goldfranks Toxicologic Emergencies. 9th ed. Stamford, CT: Appleton & Lange; 2010:1091-1102.
  • Jones áJH, Weir áWB. Cocaine-associated chest pain. Med Clin North Am. 2005;89:1323-1342.
  • June áR, Aks áSE, Keys áN, et al. Medical outcome of cocaine bodystuffers. J Emerg Med. 2000;18:221-224.
  • Kalimullah áEA, Bryant áSM. Case files of the medical toxicology fellowship at the Toxikon Consortium in Chicago: Cocaine-associated wide-complex dysrhythmias and cardiac arrest-treatment nuances and controversies. J Med Toxicol. 2008;4:277-283.

Codes

ICD9

970.81 Poisoning by cocaine á

ICD10

  • T40.5X1A Poisoning by cocaine, accidental (unintentional), init
  • T40.5X4A Poisoning by cocaine, undetermined, initial encounter
  • T40.5X2D Poisoning by cocaine, intentional self-harm, subs encntr

SNOMED

  • 9982009 Poisoning by cocaine (disorder)
  • 216583009 Accidental poisoning by cocaine (disorder)
  • 290545007 Cocaine poisoning of undetermined intent (disorder)
  • 290544006 Intentional cocaine poisoning (disorder)