Basics
Description
- Sympathomimetic
- Inhibits neurotransmitter reuptake at the nerve terminal
- Metabolism:
- Hepatic degradation
- Nonenzymatic hydrolysis
- Cholinesterase 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:
- HTN
- Tachycardia
- Chest pain (angina)
- Respiratory:
- Tachypnea
- Pleuritic chest pain:
- Pneumomediastinum
- Pneumothorax
- Bronchitis
- Pulmonary infarction
- Cough
- CNS:
- Agitation
- Tremulousness
- Coma
- Seizures
- Stroke
- 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 epithelium
- Rhabdomyolysis
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 skin
- Bowel sounds present
- Temperature (increased)
- No urinary retention
- Anticholinergic:
- Heart rate (tachycardia)
- BP (increased)
- Dry skin
- Bowel sounds diminished
- Temperature (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 pain
- Abnormal results on ECG
- CPK for evidence of myoglobinuria
- Toxicology screen
Imaging
- ECG:
- For anginal chest pain
- Consider possibility of myocardial infarction with cocaine-related chest pain.
- CXR:
- For chest pain or shortness of breath
- Check for pneumomediastinum, pneumothorax, aortic rupture.
- 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 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 headache
- Detects 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 tremor
- Initial agents for hypertension and tachycardia
- Cooling measures for hyperthermia:
- Evaporative-convective method
- Treat rhabdomyolysis:
- Hydrate with 0.9% NS
- Alkalinization with IV bicarbonate in severe cases
- Cardiac chest pain:
- Aspirin
- Nitrates
- Oxygen
- Opiates
- Avoid β-blockers because of unopposed ╬▒-stimulation
- Angiography/angioplasty/thrombolysis for acute myocardial infarction
- HTN/tachycardia:
- Benzodiazepine initial agent
- Use ╬▒-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 stuffers
- Whole-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)