Cocaine Poisoning

Key Features

• 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

Clinical Findings

• 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

Diagnosis

• 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

Treatment

• 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