Acute Cocaine Toxicity

Other than alcohol, cocaine toxicity accounts for the highest number of acute drug-related ED visits in the US.

• Cardiovascular – leads to activation of the sympathetic nervous system, leading to tachycardia, hypertension, pupillary dilatation, sweating, nausea, etc.   Can also lead to acute coronary syndrome and MI, through coronary vasoconstriction/vasospasm, increase in myocardial O2 demand, and increased thrombus formation.  Can also cause arrhythmias and direct myocardial toxicity/negative inotropic effect leading to heart failure, and rarely aortic dissection.  Chronically, leads to accelerated atherosclerosis, LVH, and dilated cardiomyopathy.

• Neuro - anxiety, irritability, panic attacks, and psychosis.  Can also lead to CNS ischemia leading to strokes, as well as intracranial hemorrhage.  Also can cause seizures. 

• Pulmonary – smoking crack can lead to cough, SOB/wheezing,exacerbation of asthma, increased susceptibility to infection, as well as “Crack Lung” – syndrome of fever, SOB, hypoxia, diffuse alveolar infiltrates, often with eosinophilia.  Can also cause hemoptysis, pulmonary hemorrhage, pulmonary edema, pneumothorax, pneumomediastinum. Intranasal snorting can lead to sinusitis and nasal perforation.

• GI – main concern is due to vasoconstriction and ischemia, leading to GI ulcers, infarcts, and mesenteric ischemia. 

• Musculoskeletal - can lead to muscle pain, rhabdomyolysis, and even compartment syndrome.

Diagnosis: Best test is urine tox screen, which can detect cocaine metabolites on average ~3 days after use (and even longer for heavy users).

Management: Supportive and involves ABCs of course as well as gastric decontamination, but also BZDs can be useful to combat the increased sympathetic drive and psychomotor agitation.  For cocaine-induced hypertension, use alpha-blockers like phentolamine, and nitroglycerin or calcium channel blockers if concern for cardiac ischemia.  Avoid beta-blockers due to concern for unopposed alpha-receptor stimulation, leading to further ischemia.  

(Chanu Rhee MD, 11/18/10)