Fast Five Quiz: Drug Overdoses

Richard H. Sinert, DO

Disclosures

October 23, 2019

According to American Heart Association guidelines, clear evidence suggests that cocaine can precipitate acute coronary syndrome, and that trying agents that show efficacy in the management of acute coronary syndrome may be reasonable in patients with severe cardiovascular toxicity. Agents that may be used as needed to control hypertension, tachycardia, and agitation include:

  • Alpha-blockers (eg, phentolamine)

  • Benzodiazepines (eg, lorazepam, diazepam)

  • Calcium channel blockers (verapamil)

  • Morphine

  • Sublingual nitroglycerin

The American Heart Association does not recommend any one of these agents over another in the treatment of cardiovascular toxicity due to cocaine; however, benzodiazepines are often used as first-line treatment.

Cardiopulmonary complaints are the most common presenting manifestations of cocaine abuse and include chest pain (frequently observed in long-term use or overdose), MI, arrhythmia, and cardiomyopathy. In individuals with cocaine-associated MI, median times to the onset of chest pain vary with the route or form of cocaine use: 30 minutes for intravenous use, 90 minutes for crack, and 135 minutes for intranasal use.

Temperature dysregulation is also a problem with cocaine intoxication. Hyperthermia is a marker for severe toxicity, and it is associated with numerous complications, including renal failure, disseminated intravascular coagulation, acidosis, hepatic injury, and rhabdomyolysis. Dopamine plays a role in the regulation of core body temperature, so increased dopaminergic neurotransmission may contribute to psychostimulant-induced hyperthermia in cocaine users, including those with excited delirium.

No laboratory studies are indicated if the patient has a clear history of cocaine use and mild symptoms.

If a history of cocaine use is absent or if the patient has moderate to severe toxicity, appropriate laboratory tests may include:

  • CBC count

  • Electrolytes, blood urea nitrogen, creatinine, and glucose levels (basic metabolic panel)

  • Glucose level

  • Pregnancy test

  • Calcium level

  • ABG analysis

  • CK level

  • Troponin level (cocaine use does not affect the specificity of troponin assays)

  • Urinalysis

  • Toxicology screens

Read more about cocaine toxicity.

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