Management of Cocaine Overdose

Immediate Resuscitation and Stabilization

The American Heart Association recommends applying standard BLS and ACLS algorithms without modification for cocaine-induced cardiac arrest, as this approach has demonstrated 55% neurologically intact survival in case series 1
Specific antidotes are reserved for the post-resuscitation phase if severe cardiotoxicity or neurotoxicity persists 1
Hyperthermia requires aggressive cooling measures as it is rapidly life-threatening and associated with increased mortality 4

The American College of Cardiology recommends administering benzodiazepines (lorazepam or diazepam) as first-line treatment for hypertension, tachycardia, and agitation (Class IIa recommendation) 2, 3, 5
Add sublingual or IV nitroglycerin for chest pain or persistent hypertension 2, 5
Calcium channel blockers (diltiazem 20 mg IV or verapamil) can be used for persistent cardiovascular instability 2, 3, 5
Morphine may be added for chest discomfort (Class IIa recommendation) 2, 3
Avoid pure beta-blockers in acute cocaine intoxication due to risk of unopposed alpha-adrenergic stimulation causing coronary vasospasm 5, 6

Obtain immediate 12-lead ECG to identify ST-segment elevation, which fundamentally changes management 5
High-risk features requiring monitored admission include: ST-elevation or depression ≥1 mm, elevated cardiac markers, recurrent chest pain, or hemodynamic instability 5, 6
Troponin I and T are preferred biomarkers over CK-MB, as CK can be elevated from skeletal muscle activity and rhabdomyolysis without myocardial infarction 6
For ST-elevation MI, proceed immediately to PCI rather than fibrinolytic therapy, as cocaine users frequently have contraindications to thrombolytics 5, 6
Use bare-metal stents rather than drug-eluting stents due to shorter required duration of dual antiplatelet therapy, as cocaine users are unreliable with prolonged adherence and face high risk of in-stent thrombosis 5, 6

Screen for life-threatening complications beyond MI: aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy (Class I recommendation) 5
Serial vital sign assessment is crucial in patients with cardiovascular complications 5
Low to intermediate-risk patients without high-risk features can be safely managed in a chest pain observation unit for 9-12 hours with clinical and ECG monitoring plus repeat troponin measurements 6
Only 0.7% to 6% of patients with cocaine-associated chest pain actually have myocardial infarction 6

Carefully dose medications to avoid hypotension after cocaine metabolism, as cocaine's effects are transient 2, 3
Prompt consultation with a medical toxicologist is strongly recommended for severe cases 3
The combination of cocaine with alcohol or cigarettes intensifies cardiovascular effects 4