Treatment of Cocaine Toxicity

Immediate Stabilization and Life-Threatening Complications

The American Heart Association recommends rapidly cooling patients with life-threatening hyperthermia using evaporative or immersive cooling modalities, as these reduce temperature faster than cooling blankets or cold packs 1
Hyperthermia results from cocaine-induced hypermetabolism and significantly increases toxicity and mortality, according to the American College of Cardiology 1, 3
The American Heart Association suggests administering benzodiazepines (lorazepam or diazepam) as first-line treatment for hypertension, tachycardia, chest pain, and agitation 2
Phentolamine (an alpha-adrenergic antagonist) is reasonable for cocaine-induced coronary vasospasm or hypertensive emergencies, as recommended by the American College of Cardiology 1, 3
The American Heart Association advises against administering pure beta-blockers in acute cocaine intoxication, as they cause unopposed alpha-adrenergic stimulation leading to paradoxical coronary vasospasm 1, 3, 2

The American Heart Association recommends applying standard BLS and ACLS algorithms without modification for cocaine-induced cardiac arrest 2
For wide-complex tachycardia or cardiac arrest, the American College of Cardiology suggests administering sodium bicarbonate (1-2 mEq/kg IV bolus) to reverse sodium channel blockade 1, 3
Lidocaine is reasonable for wide-complex tachycardia, as it competitively binds cocaine at sodium channels and reverses QRS prolongation, according to the American Heart Association 1

The American College of Cardiology recommends obtaining immediate 12-lead ECG to identify ST-segment elevation 2
High-risk features requiring monitored admission include: ST-elevation or depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability, as defined by the American Heart Association 2
The American College of Cardiology suggests using troponin I and T as preferred biomarkers over CK-MB, since CK can be falsely elevated from skeletal muscle activity and rhabdomyolysis 2

The American College of Cardiology recommends proceeding immediately to PCI rather than fibrinolytic therapy, as cocaine users frequently have contraindications to thrombolytics 2
The American Heart Association suggests using bare-metal stents rather than drug-eluting stents due to shorter required duration of dual antiplatelet therapy and poor medication adherence in this population 2

The American Heart Association recommends screening for life-threatening complications beyond MI: aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy 2
Serial vital sign assessment is crucial in patients with cardiovascular complications, according to the American College of Cardiology 2

The American College of Cardiology advises carefully dosing medications to avoid hypotension after cocaine metabolism, as cocaine's effects are transient but treatment effects persist 2
The American Heart Association recommends avoiding beta-blockers within 72 hours of cocaine use due to risk of potentiating coronary vasospasm 4, 2
The combination of cocaine with alcohol or cigarettes intensifies cardiovascular effects, according to the American College of Cardiology 2
The American Psychiatric Association suggests evaluating and treating coexisting psychiatric disorders (depression, anxiety, bipolar disorder) that are common in cocaine users 4