Death from drugs

Cocaine intoxication provides a hypertensive crisis, sodium channel blockade, a dose of serotonin, inflammation from the debris, and potential acute and chronic injury from the portal of entry. So we need a systematic method to consider complications while stabilizing the patient.

A: Apply C-spine and Assess airway

• C-spine injury from fall
• aspiration risk

B: CHEST

• Collapse: pneumothorax/pneumomediastimum from barotrauma if inhaled
• Hyperinflation: bronchospasm
• Edema/effusion: alveolar hemorrhage

C: CARDIOVASCULAR

• Cardiac arrhythmia from sodium channel blockade
• Dysfunctional LV: acute coronary syndrome from thombosis, vasospasm or coronary artery dissection; chronic cardiomyopathy
• Incompetent valve: infective endocarditis from IV drug use
• Outflow: aortic dissection

D: NEUROLOGIC

• Neuron seizure
• Encephalitis/meningitis/abscess from eroded sinus
• RBC bleed/clot from hypertensive surge or embolic

E: ENDO

• Normothermia: fever from sympathetic surge, infection or serotonin syndrome

F: CREATININE, PELVIS

• Renal artery thrombosis
• Extracellular circulating volume reduction
• ATN from rhabdo
• Pregnancy: placental abruption

G: ABDOMINAL

• Mesenteric ischemia:, especially if cocaine pack in abdomen leaks

H: HEME

• thrombocytopenia

I: INTOX

• co-ingestants

Joints/skin/bones

• ortho injuries from falls
• vasculitis from levamisole-laced cocaine
• soft tissue infection from injection, picking at skin

Putting this together, the main treatment is supportive care: oxygen and benzos, and basic investigations–ECG +/- CXR, Cr/UA, CK. But consider system-based complications and further investigations:

• A: assess and protect C-spine and airway
• B: provide oxygen, POCUS for pneumothorax, CXR for pneumothorax/pneumomediastinum/infiltrates if hypoxic
• C: benzos for hypertensive surge; ECG assess sodium channel blockade, ACS (DDx: dissection); look for signs of endocarditis
• D: benzos for seizure; consider bleed/stroke, meningitis/abscess, or serotonin syndrome if altered
• E: benzos for fever, consider sepsis and serotonin syndrome
• F: check UA/Creatinine/CK, consider renal artery thrombosis; assess pregnancy
• G: if abdo pain consider mesenteric ischemia (and dissection)
• H: check Platelets
• I: consider co-ingestants
• J: r/o injuries, infections