Jun 30, 2016
Author: Lynn Barkley Burnett, MD, EdD
Nearly every organ system can be affected by cocaine toxicity. Aside from alcohol (and not including tobacco-related illnesses), cocaine is the most common cause of drug-related emergency department (ED) visits in the United States, accounting for 505,224 ED visits in 2011, or 162.1 ED visits per 100,000 population.  See the image below.
CT scan of patient transporting cocaine packets.
See Can’t-Miss Gastrointestinal Diagnoses, a Critical Images slideshow, to help diagnose the potentially life-threatening conditions that present with gastrointestinal symptoms.
Signs and symptoms
There are 3 reported phases of acute cocaine toxicity. In fatal cases, the onset and progression are accelerated, with convulsions and death frequently occurring in 2-3 minutes, though sometimes in 30 minutes.
Phase I (early stimulation) is as follows:
Central nervous system (CNS) findings: Mydriasis, headache, bruxism, nausea, vomiting, vertigo, nonintentional tremor (eg, twitching of small muscles, especially facial and finger), tics, preconvulsive movements, and pseudohallucinations (eg, cocaine bugs)
Circulatory findings: Possible increase in blood pressure (BP), slowed or increased pulse rate (possibly with ventricular ectopy), and pallor
Respiratory findings: Increase in rate and depth
Temperature findings: Elevated body temperature
Behavioral findings: Euphoria, elation, garrulous talk, agitation, apprehension, excitation, restlessness, verbalization of impending doom, and emotional lability
Phase II (advanced stimulation) is as follows:
CNS findings: Malignant encephalopathy, generalized seizures and status epilepticus, decreased responsiveness to all stimuli, greatly increased deep tendon reflexes, and incontinence
Circulatory findings: Hypertension; tachycardia; and ventricular dysrhythmias (possible), which then result in weak, rapid, irregular pulse and hypotension; and peripheral cyanosis
Respiratory findings: Tachypnea, dyspnea, gasping, and irregular breathing pattern
Temperature – Severe hyperthermia (possible)
Phase III (depression and premorbid state) is as follows:
CNS: Coma, areflexia, pupils fixed and dilated, flaccid paralysis, and loss of vital support functions
Circulatory: Circulatory failure and cardiac arrest (ventricular fibrillation [VF] or asystole)
Respiratory: Respiratory failure, gross pulmonary edema, cyanosis, agonal respirations, and paralysis of respiration
See Clinical Presentation for more detail.
If history is absent or if the patient has moderate to severe toxicity, appropriate laboratory tests may be ordered, including the following:
Complete blood count (CBC)
Electrolytes, blood urea nitrogen (BUN), creatinine, glucose (chem-7)
Arterial blood gases (ABG) analysis
Creatine kinase (CK) level
Urinalysis (UA): Can aid in finding cocaine-induced rhabdomyolysis, the reported incidence of which is 5-30% in ED patients who use cocaine
Toxicology evaluations: Including for urine, blood, gastric contents, and unknown substances clinging to the patient’s body
See Workup for more detail.
Chest radiographs, which should be obtained in patients with chest pain, hypoxia, or moderate to severe cocaine toxicity, may reveal the following:
Diffuse granulomatous changes: In cases of chronic parenteral cocaine use, due to the injection of inert insoluble ingredients of oral preparations or insolubles used to cut cocaine (eg, talc)
Septic pulmonary emboli: Appear round or wedge shaped; they may clear rapidly or cavitate
Aspiration pneumonitis and noncardiogenic pulmonary edema
Pulmonary abscess: May become evident after aspiration pneumonitis or after an intravenous injection of bacteria or toxic organic or inorganic materials
Aneurysm or pseudoaneurysm: May be noted with mainlining, directly injecting into a central artery or vein; this finding is an indication for further imaging studies
In addition, radiography may be useful for evaluating cellulitis, an abscess, or a nonhealing wound in an intravenous drug user revealing foreign body or subcutaneous emphysema produced by gas-forming organisms in an anaerobic infection. Ultrasonography may identify a foreign body or abscess.
Skeletal images can reveal osteomyelitis or fractures. However, because osteomyelitis may not be demonstrable on plain images for 1-2 weeks, other imaging studies should be performed if such a diagnosis is considered.
Obtain a 12-lead electrocardiogram (ECG) in patients with chest pain; hypoxia; dyspnea; an irregular, rapid, or slow pulse; altered mental status; or moderate to severe toxicity.
The general objectives of pharmacotherapeutic intervention in cocaine toxicity are to reduce the CNS and cardiovascular effects of the drug by using benzodiazepines initially and then to control clinically significant tachycardia and hypertension while simultaneously attempting to limit deleterious drug interactions.
Hyperthermia and rhabdomyolysis
If psychostimulant-intoxicated patients do not die as a result of cardiac or cerebrovascular complications, it is essential to prevent further morbidity by controlling hyperthermia and treating rhabdomyolysis.
Hyperthermia may be treated with convection cooling, which involves spraying the patient’s exposed body with tepid water as fans circulate air.
Rapid fluid resuscitation promotes urine output and alleviates the effect of myoglobin on the kidneys. Generous amounts of intravenous fluids with close monitoring of urine output and pH are indicated for rhabdomyolysis associated with severe psychostimulant toxicity.
See Treatment and Medication for more detail.