Treatment for Cocaine Toxicity

" Treatment of mild cocaine intoxication is generally unnecessary because the drug is extremely short-acting. Benzodiazepines are the preferred initial treatment for most toxic effects, including CNS excitation and seizures, tachycardia, and hypertension. Lorazepam 2 to 3 mg IV q 5 min titrated to effect may be used. High doses and a continuous infusion may be required. Propofol infusion, with mechanical ventilation, may be used for resistant cases. Hypertension that does not respond to benzodiazepines is treated with IV nitrates (eg, nitroprusside) or phentolamine; ?-blockers are not recommended because they allow continued ?-adrenergic stimulation. Hyperthermia can be life threatening and should be managed aggressively with sedation plus evaporative cooling, ice packs, and maintenance of intravascular volume and urine flow with IV normal saline solution. Phenothiazines lower seizure threshold, and their anticholinergic effects can interfere with cooling; thus, they are not preferred for sedation. Occasionally, severely agitated patients must be pharmacologically paralyzed and mechanically ventilated to ameliorate acidosis, rhabdomyolysis, or multisystem dysfunction.
"Cocaine-related chest pain is evaluated as for any other patient with potential myocardial ischemia or aortic dissection, with chest x-ray, serial ECG, and serum cardiac markers. As discussed, ?-blockers are contraindicated, and benzodiazepines are a first-line drug. If coronary vasodilation is required after benzodiazepines are given, nitrates are used, or phentolamine 1 to 5 mg IV given slowly can be considered."