Cocaine toxicity occurs within minutes to hours of excessive cocaine use.
Some patients may die suddenly before treatment is given.
Presentation includes tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis, and agitation.
Urine cocaine screen confirms recent cocaine use, but treatment should not be delayed pending results of the test.
Treatment may involve supportive care and benzodiazepines; hyperthermia requires rapid cooling to prevent death.
Complications such as dysrhythmias, acute coronary syndrome, and intracranial haemorrhage can occur.
Cocaine is a drug of abuse that is usually either insufflated (snorted), injected, or smoked in its freebase form (crack). Cocaine is a type IC anti-dysrhythmic, local anaesthetic, and sympathomimetic. Cocaine toxicity refers to adverse events that occur in the setting of cocaine use. These events, which can occur in combination or isolation, include hyperthermia, rhabdomyolysis, dysrhythmia, ischaemia, intracranial haemorrhage, agitation, psychosis, and seizures.
History and exam
Key diagnostic factors
- presence of risk factors
Other diagnostic factors
- high ambient temperature
- cocaine body packing
- male sex
- plasma cholinesterase deficiency
- age 18-25 years
- history of cocaine use
- concomitant use of other sympathomimetics
1st investigations to order
- bedside serum glucose
- serum creatinine
- serum creatine phosphokinase (CPK)
- serum troponin
- chest x-ray
- CT scan of brain
Investigations to consider
- urine cocaine assay
- CT scan of abdomen and pelvis
suspected/confirmed cocaine toxicity: non-body packer/stuffer
suspected/confirmed cocaine toxicity: body packer/stuffer
Andrew Stolbach, MD, MPH
Johns Hopkins Hospital
AS has been reimbursed by Peerview Education for delivering educational lectures unrelated to this topic; for expert testimony in unrelated toxicology topics; and by UpToDate for writing articles on other toxicology topics.
Janice Zimmerman, MD
Critical Care Division
The Methodist Hospital
JZ declares that she has no competing interests.
Alison Jones, MD, FRCPE, FiBIOL, FRCP, FRACP
School of Medicine
University of Western Sydney
AJ declares that she has no competing interests.
Andrew Parfitt, MBBS, FFAEM
Associate Medical Director
Consultant Emergency Medicine
Guy's and St Thomas' NHS Foundation Trust
Clinical Lead and Consultant
Accident Emergency Medicine
St Thomas' Hospital
AP declares that he has no competing interests.
- Non-cocaine sympathomimetic overdose
- Alcohol, sedative or hypnotic withdrawal
- Anticholinergic syndrome
- European Resuscitation Council guidelines 2021: cardiac arrest in special circumstances
- Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
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