Cocaine Toxicity

Use continuous clinical reassessment and ECG-based monitoring in patients with significant toxicity, particularly when there is altered mental status, chest pain, marked autonomic activation, seizure, or suspected dysrhythmia. Toxicity monitoring described in arrhythmia guidance includes serial history and examination, ECG, and chest radiography when clinically indicated. AHA JournalsAHA Journals2017 AHA/ACC/HRS Guideline for Management of Patients With ...

Prioritize control of severe agitation and prevention or treatment of hyperthermia. In stimulant intoxication, rhabdomyolysis most often follows severe agitation and hyperthermia; obtain serum creatine phosphokinase when either is present, follow renal function, and replace fluids to target urine output greater than 2 mL/kg/h. Avoid urinary alkalinization in this setting because it inhibits amphetamine elimination; management should instead focus on fluids and control of agitation and hyperthermia. CDCCDC[PDF] The ASAM/AAAP Clinical Practice Guideline on the ... - CDC Stacks

Treat seizures and persistent movement disorders as complications requiring ongoing renal surveillance. The ASAM/AAAP guideline specifically advises routine and repeated renal-function screening in stimulant-intoxicated patients with seizures or movement disorders. CDCCDC[PDF] The ASAM/AAAP Clinical Practice Guideline on the ... - CDC Stacks

Obtain an ECG promptly and evaluate for acute coronary syndrome in every patient with cocaine-associated chest pain. ECG abnormalities have been reported in 56% to 84% of patients with cocaine-associated chest pain, and left ventricular hypertrophy can obscure regional ischemic changes; therefore, an abnormal ECG alone does not establish the mechanism of pain, while ischemic changes should trigger an ACS pathway. AHA JournalsAHA JournalsManagement of Cocaine-Associated Chest Pain and Myocardial ...

Use serial symptom assessment and evaluation for myocardial ischemia when determining disposition. In the NEJM observation study, patients with cocaine-associated chest pain still required evaluation for acute coronary syndromes; the brief observation strategy was limited to patients without recurrent symptoms or evidence of acute ischemia. NEJMNEJMValidation of a Brief Observation Period for Patients with Cocaine ...

Maintain a separate aortic-dissection branch for abrupt severe pain, pulse or neurologic asymmetry, a new diastolic murmur, mediastinal abnormality, or shock. Cocaine-associated aortic dissection and rupture have been reported; do not initiate an MI-only pathway until dissection is reasonably excluded when clinical features suggest acute aortic syndrome. annemergmedannemergmedThe Cardiovascular Effects of Cocaine

Activate urgent stroke evaluation for any focal deficit, acute aphasia, persistent altered consciousness, severe sudden headache, or seizure. Cocaine’s sympathomimetic effects are associated with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage; a systematic review and meta-analysis reported an odds ratio of 5.05 for ischemic or hemorrhagic stroke among cocaine users. PubMedPubMedCocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence - PubMed

Anticipate a more complicated course in cocaine-associated stroke. Compared with stroke without cocaine association, the meta-analysis found higher odds of mortality (OR 1.77), vasospasm (OR 2.25), and seizures (OR 1.61). These associations support close neurologic monitoring and early escalation when seizures or worsening deficits occur. PubMedPubMedCocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence - PubMed

Consider hyperthermia a marker of potentially escalating multisystem injury, especially during hot weather, when cocaine-attributed deaths have been noted to be more frequent and hyperthermia more likely. WHOWHO[PDF] Managing ART in Injecting Drug Users - IRIS Pair temperature control with assessment for agitation-associated rhabdomyolysis and renal injury. CDCCDC[PDF] The ASAM/AAAP Clinical Practice Guideline on the ... - CDC Stacks

Ask directly about cocaine and other drug exposure in patients with chest pain, agitation, hyperthermia, seizure, and unexplained neurologic events. In a survey of clinicians caring for cocaine-associated chest pain, many did not routinely ask all chest-pain patients about drug use, despite regarding cocaine use as an ACS risk factor. ScienceDirectScienceDirectThe current practice for cocaine-associated chest pain in the Netherlands - ScienceDirect

Interpret urine or broad toxicology testing cautiously. Drug and metabolite detection may reflect prior rather than current clinical state, and the usefulness of broad-spectrum testing depends on the interval from exposure and the detection window. Use results to support or redirect a differential when timely, particularly if history is unavailable or polysubstance exposure is plausible, but make treatment decisions from current physiology and competing emergency diagnoses. ScienceDirectScienceDirectToxicology Testing - an overview | ScienceDirect Topics

Obtain targeted complication testing when the presentation directs it: ECG for chest pain or dysrhythmia concern, serum creatine phosphokinase and renal-function testing for severe agitation, hyperthermia, seizure, or movement disorder, and urgent stroke evaluation for focal neurologic findings. AHA Journals+2AHA Journals2017 AHA/ACC/HRS Guideline for Management of Patients With ...CDC[PDF] The ASAM/AAAP Clinical Practice Guideline on the ... - CDC StacksPubMedCocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence - PubMed

Consider a brief observation pathway only for cocaine-associated chest pain after evaluation for acute coronary syndrome when there are no recurrent symptoms and no evidence of acute ischemia. Patients with recurrent pain, ischemic evidence, unstable vital signs, dysrhythmia, seizure, hyperthermia, rhabdomyolysis, renal injury, or acute neurologic deficits require continued monitored management directed at the identified complication. NEJM+2NEJMValidation of a Brief Observation Period for Patients with Cocaine ...CDC[PDF] The ASAM/AAAP Clinical Practice Guideline on the ... - CDC StacksPubMedCocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence - PubMed

Continue reassessment of temperature, mental status, cardiovascular status, ECG findings, urine output, renal function, and creatine phosphokinase in patients with severe sympathomimetic manifestations. The combination of severe agitation and hyperthermia should lower the threshold for monitoring rhabdomyolysis and kidney injury. CDCCDC[PDF] The ASAM/AAAP Clinical Practice Guideline on the ... - CDC Stacks

Before discharge after an uncomplicated course, address recurrence risk through substance-use counseling and linkage to treatment. Cocaine cessation is specifically emphasized in the stroke literature because cocaine-associated cerebrovascular events carry higher odds of mortality, vasospasm, and seizures. PubMedPubMedCocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence - PubMed