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Key Features

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  • Cocaine is absorbed intranasally or via inhalation or ingestion

  • A local anesthetic and vasoconstrictor, cocaine is also a potent stimulant to both the CNS and the cardiovascular system

  • Effects are noted almost immediately when the drug is taken intravenously or smoked

  • Peak effects are delayed for about an hour when the drug is taken orally or nasally

  • In addition to those poisoned through recreational use of cocaine, others are at risk of overdose

    • A "body stuffer" is one who quickly ingests the drug, usually poorly wrapped, to avoid discovery; toxicity typically manifests within hours of ingestion

    • A "body packer" wraps the drug carefully for prolonged transport; person is asymptomatic unless the package ruptures, usually days later

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Clinical Findings

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  • Tachycardia, hyperpnea, hypertension, and stimulation of the CNS are often followed by coma, seizures, hypotension, and respiratory depression

  • In severe cases of overdose, various dysrhythmias may be seen, including sinus tachycardia, atrial arrhythmias, premature ventricular contractions, bigeminy, and ventricular fibrillation

  • If large doses are taken intravenously, cardiac failure, dysrhythmias, rhabdomyolysis, or hyperthermia may result in death

  • Newborns of cocaine using mothers may continue to have seizures for months after birth

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Diagnosis

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  • Testing for cocaine in blood or plasma is generally not clinically useful

  • A qualitative analysis of the urine may aid in confirming the diagnosis

  • For severe cases, an ECG is indicated

  • In suspected cases of body packing, radiographs of the GI tract may show multiple packets, but are usually not helpful for identifying stuffers

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Treatment

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  • Activated charcoal should be considered in body stuffers

  • Whole bowel irrigation may be useful in cases of body packers

  • Seizures are treated with intravenous benzodiazepines such as lorazepam, titrated to response; agitation is best treated with a benzodiazepine

  • Hypotension is treated with standard agents

  • Because cocaine abuse may deplete norepinephrine, an indirect agent such as dopamine may be less effective than a direct agent such as norepinephrine

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