
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