approach to cocaine intoxication

Death from drugs

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

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