Cocaine Toxicity - Symptoms, Stages, and Management

Introduction

Cocaine is a highly addictive powerful stimulant. Cocaine can be swallowed, injected, snorted, or smoked. Cocaine induces a state of altered consciousness (euphoria) and hypersensitivity to outside stimuli. Cocaine abuse is a global health condition. Acute cocaine toxicity due to cocaine overdose requires urgent medical treatment for the rapid heartbeat (tachycardia), dysrhythmia (irregular heartbeat), hypertension (increased blood pressure), and coronary vasospasm to prevent pathological sequelae such as acute coronary syndrome, stroke, and death.

What Is Cocaine?

Cocaine is a highly addictive stimulant drug. It is a tropane alkaloid obtained from the coca plant leaves (Erythroxylum coca, Erythroxylum novogranatense) native to South America. Cocaine is used for valid medical purposes as local anesthesia for some surgeries. However, continuous recreational use of cocaine is highly addictive and results in altered brain structure and function.

Cocaine is a drug with a high tendency for abuse leading to psychological and physical dependence (included in schedule II drugs). Cocaine can be used by a healthcare professional for accepted medical use. People use cocaine powder by snorting through the nose, rubbing on gums, and injecting it into the bloodstream. Cocaine enhances the activity of norepinephrine, dopamine, and serotonin in the central nervous system. Norepinephrine activity increases heart rate, blood pressure, body temperature, and dilated pupils.

What Is Cocaine Toxicity?

Cocaine toxicity is a condition that results from high doses of cocaine in the body. It affects the central nervous and cardiovascular systems and leads to life-threatening complications. Cocaine overdose usually happens when a user ingests too much of the drug or uses more and more to maintain their dose. Cocaine causes a state of altered consciousness called high. The high lasts for more than an hour. To maintain this state, users inject large amounts, which results in toxicity.

The amount of cocaine causing toxicity depends on the individual and unique circumstances. Method of ingestion (orally, nasally, and intravenously) plays an essential role in toxicity. Intravenous (injected) cocaine produces a fatal reaction with a small dose of 20 milligrams. Mixing cocaine with other substances like heroin and alcohol exacerbates the fatal response to overdose. Dependence on the drug and recurrent cocaine use reduces the desired effects perceived by the users and increases the adverse effects and toxicity. Studies have shown that cocaine use during pregnancy triggers premature birth and early separation of the placenta from the uterus (placental abruption).

What Are the Symptoms of Cocaine Toxicity?

• Hypertension (increased blood pressure).

• Altered mental status.

• Seizure (altered consciousness, uncontrollable muscle spasms, falling, sudden eye movements).

• Chest pain, dyspnea (shortness of breath).

• Epistaxis (bleeding from the nose).

• Headache.

• Paranoia (intense anxious feeling of being threatened ).

• Neurological deficits.

• Hyperthermia (high body temperature).

• Vascular spasm and loss of distal pulses.

• Extreme diaphoresis (abnormal sweating).

• Severe agitation, restlessness, confusion.

• Pruritus (an uncomfortable, irritating sensation).

• The blurring of vision.

• Corneal ulceration and vision loss.

• Diarrhea.

• Vomiting.

• Abdominal pain.

• Excited delirium (an acute confusional state with intense hallucinations and violence towards objects and people).

What Are the Stages of Cocaine Toxicity?

Acute cocaine toxicity is divided into three stages. It includes the following:

Stage 1 of Acute Cocaine Toxicity.

• Begins with symptoms in the central nervous system (CNS) - Headache, nausea, mydriasis, vertigo, twitching, pseudohallucinations, and pre-convulsive movements.

• Vascular - Increased blood pressure and ectopic beats.

• Pulmonary - Tachypnea (rapid breathing).

• Skin - Hyperthermia (increased body temperature).

• Psychiatric - Paranoia (extreme feeling that other people do not like them or are going to harm or criticize them), euphoria (state of intense excitement or happiness), confusion, aggression, agitation, emotional lability, and restlessness.

Stage 2 of Acute Cocaine Toxicity.

• Central Nervous System (CNS) - Encephalopathy (toxin-induced functional damage to the brain), seizures, increased deep tendon reflexes, incontinence (reduced control over the urine flow).

• Cardiovascular system (CVS) - Hypertension, arrhythmias(irregular heartbeat), peripheral cyanosis (fingers turn blue).

• Pulmonary - Tachypnea, gasping (struggling to breathe), apnea, irregular breathing.

• Skin - Hyperthermia.

Stage 3 of Acute Cocaine Toxicity.

• Most dangerous and can result in death.

• Areflexia (loss of deep tendon reflexes), fixed and dilated pupils, loss of vital functions, coma.

• Cardiovascular systems like hypotension (decreased blood pressure), ventricular fibrillation (rapid heartbeat), and cardiac arrest (heart attack).

• Pulmonary symptoms like apnea, respiratory failure, cyanosis, and agonal breathing (abnormal breathing).

How to Manage Cocaine Toxicity?

There is no specific antidote (remedy to counteract the effects of poison) for cocaine toxicity. Therefore, the medical intervention is based on treating the principal symptoms of the overdose.

It includes:

1. Emergency medical care must be provided to patients with cocaine toxicity. ABCDE approach (airway, breathing, circulation, disability, exposure) to emergency management should be made.

2. Patients must be kept away from sharp objects and edges to prevent injury during seizures.

3. If someone feels overheated (hyperthermia), try to keep their body temperature down with cold compresses.

4. Manage the patient's fever.

5. Hypoglycemia as a cause of neuropsychiatric symptoms should be ruled out.

6. Benzodiazepines are the first-line drug in patients with cardiovascular toxicity and agitation to lower their blood pressure and heart rate. Antipsychotics such as Haloperidol and Olanzapine can also be used.

7. Aspirin can be used for chest pain associated with toxicity.

8. Blood pressure can be lowered by using Nitroprusside and Nitroglycerin. They also help in reversing coronary arterial vasoconstriction.

9. Alpha-blockers such as Phentolamine can be used to treat cocaine-induced hypertension and coronary artery vasoconstriction.

10. A non-selective beta-blocker and selective alpha-1 blocker combination (Labetalol) can be used for treating hypertension and tachycardia.

11. Calcium channel blockers can also be used to treat hypertension and coronary artery vasoconstriction. Diltiazem and Verapamil (non-dihydropyridine calcium channel blockers) are preferable.

Conclusion

Cocaine toxicity occurs due to an excessive dose of cocaine in the body. Toxicity occurs within minutes to hours of excessive cocaine use. Toxicity results in various symptoms, including hyperthermia, rhabdomyolysis, dysrhythmia, ischemia, intracranial hemorrhage, agitation, psychosis, and seizures. Cocaine toxicity should be considered a life-threatening condition, and medical assistance and management should be provided immediately. There is no specific antidote treatment for toxicity. Emergency medical care is provided to stabilize the patient, and additional medications must be administered to treat other pathological effects of a cocaine overdose.