›Antipsychotics are generally avoided
›Haloperidol 5 mg IM and droperidol 2.5 mg IV lower the seizure threshold, impair heat dissipation, and prolong the QT
›If a single dose is unavoidable for danger to self or staff, obtain an ECG and prefer a low dose of droperidol over haloperidol
›They do not replace benzodiazepines for the underlying catecholamine drive
Cocaine cardiovascular management and refractory toxicity
›Blood pressure and chest pain
›A benzodiazepine first, because reducing central sympathetic outflow lowers pressure, rate, and coronary vasospasm together
›Nitroglycerin infusion 10 to 200 mcg per minute IV, titrated to symptoms and pressure
›Phentolamine 1 to 5 mg IV every 5 to 10 minutes, a non-selective alpha-adrenergic blocker that directly reverses cocaine-mediated vasoconstriction
›Aspirin 300 mg by mouth for genuine cocaine-associated acute coronary syndrome, with heparin per local protocol
›Why beta-blockers are withheld in suspected cocaine toxicity
›Esmolol bolus 500 mcg per kg then infusion 50 mcg per kg per minute, and labetalol 10 to 20 mg IV, are both avoided
›Blocking beta receptors leaves alpha-mediated vasoconstriction unopposed, worsening hypertension and coronary and end-organ ischemia
›Labetalol has too little alpha effect to overcome this and is not a safe compromise
›Calcium channel blockers are not a rate-control substitute here
›Nicardipine 5 mg per hour IV, titrated by 2.5 mg per hour every 5 to 15 minutes to a maximum 15 mg per hour, is a dihydropyridine arterial vasodilator
›It lowers pressure but causes reflex tachycardia and does not provide the negative chronotropy a beta-blocker would
›Control rate by reducing catecholamine drive with benzodiazepines rather than by adding a direct rate-slowing agent
›Dysrhythmia management
›Sodium bicarbonate 1 to 2 mmol per kg IV bolus for QRS above 120 ms, repeated to narrow the complex, keeping serum pH no higher than 7.55
›Recheck a venous gas and potassium in mmol/l 30 to 60 minutes after each bolus
›Replace potassium cautiously because a rebound rise can follow catecholamine resolution
›Lidocaine 1 to 1.5 mg per kg IV bolus then 1 to 4 mg per minute infusion as an alternative for refractory wide-complex tachycardia
›Magnesium sulfate 2 g IV over 15 minutes for torsades or frequent ventricular ectopy
›Avoid procainamide, other class Ia and Ic agents, and amiodarone 150 mg IV loading where sodium-channel blockade or marked QT prolongation is already present
›Extracorporeal and rescue therapy
›Intravenous lipid emulsion 20 percent for refractory cardiovascular collapse
›Bolus 1.5 ml per kg IV over 2 to 3 minutes, then infusion 0.25 ml per kg per minute for 30 to 60 minutes
›Repeat the bolus once or twice for persistent asystole and consider doubling the infusion rate for recurrent instability
›Do not exceed roughly 10 ml per kg cumulative; it can interfere with some laboratory assays and complicate ECMO circuits
›Venoarterial ECMO for refractory cardiogenic shock or arrest from a massive cocaine leak, arranged early
›An intra-aortic balloon pump is contraindicated if aortic dissection or significant aortic regurgitation is present, both of which cocaine can cause; prefer ECMO or a percutaneous ventricular assist device
›When cardiovascular therapy is not working
›Persisting wide-complex tachycardia despite adequate bicarbonate and lidocaine escalates to lipid emulsion and ECMO referral
›Persisting hypertensive emergency despite deep sedation and phentolamine prompts reimaging for dissection or intracranial hemorrhage
›Hypotension in late cocaine toxicity is usually cardiogenic; support with norepinephrine 0.05 to 0.5 mcg per kg per minute and treat the source surgically
Hyperthermia and seizures
›Hyperthermia is a resuscitation emergency
›Begin active cooling for a core temperature above 38.5 degrees C and target a temperature below 38.5 degrees C
›Evaporative cooling with misting and fans, ice packs to the groin and axillae, and cold isotonic IV fluid
›Cold-water immersion or a cooling blanket for a core temperature above 40 degrees C
›Deep sedation, and intubation with a non-depolarizing paralytic such as rocuronium 1.2 mg per kg IV, for hyperthermia above 40 degrees C not responding within minutes
›Antipyretics do not work here: acetaminophen 15 mg per kg IV or by mouth, maximum 1000 mg per dose, has no role because the heat is not prostaglandin-mediated
›Dantrolene 2.5 mg per kg IV is not recommended; this is not malignant hyperthermia and there is no evidence of benefit
›Seizure management
›Benzodiazepines first: lorazepam 2 to 4 mg IV or diazepam 5 to 10 mg IV, repeated once after 5 minutes
›Levetiracetam 60 mg per kg IV, maximum 4500 mg, as the second-line agent
›Phenobarbital 15 to 20 mg per kg IV for ongoing seizures, with airway control
›Phenytoin, loading dose 15 to 20 mg per kg IV, is ineffective for drug-induced seizures and is not recommended
›Reversible contributors to check
›Capillary and laboratory glucose, treating a value below 4.0 mmol/l
›Sodium in mmol/l: MDMA-associated hyponatremia is treated with 3 percent saline 100 to 150 ml IV bolus, repeated once if seizures continue, with no free water
›Persisting seizures or hyperthermia despite sedation means intubation, paralysis, and continuous EEG
Opioid toxicity and naloxone
›Naloxone for a leaking opioid packet or an opioid stuffer
›Initial 0.04 to 0.4 mg IV for respiratory depression, titrated upward every 2 to 3 minutes to restore adequate ventilation, not full arousal
›Escalate to 2 mg, then to 4 to 10 mg, before abandoning the opioid hypothesis if the history is strong
›Intramuscular 0.4 to 0.8 mg or intranasal 4 mg if there is no IV access
›Continuous infusion when repeated boluses are needed: start at two-thirds of the effective waking bolus per hour and titrate
›Reassess respiratory rate and end-tidal CO2 every 15 to 30 minutes and adjust the rate
›Expect the requirement to rise as more drug leaks; a rising requirement is itself a surgical trigger
›Precipitated withdrawal causes vomiting, aspiration risk, and a catecholamine surge; use the smallest effective dose
›Ventilatory support is co-equal with the antidote
›Bag-valve-mask ventilation and airway positioning while naloxone takes effect
›Intubate rather than chase escalating naloxone when leak is continuous and massive
›Treat non-cardiogenic pulmonary edema with oxygen and positive-pressure ventilation, not diuresis
›When naloxone is not enough
›Inability to maintain ventilation on a rising infusion means definitive surgical removal of the packets
›Do not discharge an opioid stuffer within 4 hours of the last naloxone dose given the risk of re-sedation
›Observe at least 12 to 24 hours if a sustained-release opioid or a fentanyl analogue is suspected
Definitive packet removal
›Surgical removal by laparotomy
›Indicated for rupture in a cocaine packer, obstruction, perforation, peritonitis, bleeding, or failure to progress over 24 to 48 hours
›Enterotomy and careful milking to deliver every packet intact, with a final count against imaging
›Broad-spectrum antibiotics and resuscitation before and during the procedure
›Endoscopic and manual approaches
›Flexible endoscopy is generally avoided because grasping or snaring can rupture a packet; if attempted for a gastric packet that will not pass, do it with a surgical team scrubbed
›Gently remove a low rectal or vaginal packet only under direct vision and only if it can be grasped without instruments that could tear it
›Do not use enemas or digital disimpaction to dislodge a mid-gut packet
›Post-removal monitoring
›Continue telemetry and toxidrome watch after removal, since absorbed drug persists
›Repeat imaging to confirm that no packet remains
›Keep the naloxone infusion or sedation running until the clinical picture and the count both reconcile
Supportive care, analgesia, and antibiotics
›Fluids, electrolytes, and renal protection
›Balanced isotonic crystalloid in 10 to 20 ml per kg boluses for hypotension or rhabdomyolysis
›Target urine output 1 to 2 ml per kg per hour when creatine kinase is rising
›Correct potassium and magnesium in mmol/l, rechecking after whole bowel irrigation and after bicarbonate
›Analgesia
›Small titrated fentanyl 25 to 50 mcg IV for severe abdominal pain, reassessing frequently
›Opioids slow transit, can trap packets, and can mask an evolving surgical abdomen
›Prefer non-opioid measures and surgical review over standing opioid orders
›Avoid NSAIDs such as ketorolac 15 to 30 mg IV because of acute kidney injury risk and perioperative bleeding
›Antibiotics for perforation, peritonitis, or operative management
›Piperacillin-tazobactam 4.5 g IV every 6 to 8 hours
›Or ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours
›Add coverage and source control per the operative findings
›Routine ED interventions that must be modified or withheld
›Intubation: needed for airway loss or hyperthermia; use rocuronium 1.2 mg per kg IV rather than repeat succinylcholine when hyperkalemia or rhabdomyolysis is likely
›Sedation: benzodiazepines, not antipsychotics, which lower the seizure threshold, impair cooling, and prolong the QT
›Fluid loading: give for rhabdomyolysis and hyperthermia but avoid over-resuscitation during whole bowel irrigation and in opioid-related pulmonary edema
›Oxygen: titrate to SpO2 94 to 98 percent, or 88 to 92 percent in chronic hypercapnia, and avoid hyperoxia
›Vasopressors: norepinephrine 0.05 to 0.5 mcg per kg per minute for late cardiogenic hypotension, after sedation, cooling, and bicarbonate
›Mechanical circulatory support: prefer venoarterial ECMO; an intra-aortic balloon pump is contraindicated with aortic dissection or significant aortic regurgitation
›Anticoagulation and antiplatelet agents: give for true cocaine acute coronary syndrome but withhold pending CT if there is any neurologic sign, suspected dissection, or planned laparotomy
›Fibrinolysis: avoid in cocaine-associated ST elevation because of a high false-positive rate and intracranial hemorrhage risk with uncontrolled hypertension; prefer primary PCI
›Analgesia: opioids only in small titrated doses because they trap packets and mask the abdomen