Makindo Medical Notes

Related Subjects: | Hypertension

💊 About Cocaine

• Cocaine is a potent CNS stimulant derived from the coca plant. It blocks reuptake of dopamine, serotonin, and noradrenaline → ↑ synaptic levels.
• Chronic use accelerates atherosclerosis. Euphoria is due to dopamine surge in the mesolimbic reward pathway.
• Routes: snorting (nasal mucosa absorption → local vasoconstriction, septal damage), smoking, IV injection (faster, shorter high). Less common: oral, gums, suppository.
• Still used medically as a local anaesthetic in ophthalmic & ENT surgery (provides anaesthesia + vasoconstriction).

⚠️ Clinical Features & Complications

• Chest Pain: Often due to coronary artery spasm rather than thrombus. 🚫 Avoid thrombolysis (↑ risk ICH). For persistent ST-elevation → follow STEMI PCI pathway. IV nitrates before PCI may help.
• Hyperthermia: Cocaine ↑ muscle activity and metabolism. Treat with fluids, active cooling, and dantrolene if refractory. 🚫 Avoid haloperidol/phenothiazines (lower seizure threshold). ✔️ Diazepam is preferred.
• Other Complications: Delirium, arrhythmias, MI, stroke, seizures, haemorrhagic stroke, trauma (often violent encounters). Toxicity largely due to sympathetic overdrive (tachycardia, hypertension, fever).
• Initial Management: ABCs. IV diazepam controls agitation, lowers sympathetic tone, and helps hypertension/tachycardia. Body cooling for hyperthermia. IV nitrates relieve coronary spasm.

🔬 Investigations

• Bloods: FBC, U&E, LFTs. Check CK (rhabdomyolysis risk).
• Troponin: Assess for MI from coronary spasm/atheroma.
• Toxicology: Urine/blood screen (confirm use, detect co-ingestants e.g. alcohol, benzodiazepines, opioids).
• ECG: Arrhythmias, QT prolongation, ischaemia.
• Imaging: CXR (exclude pneumothorax), CT head if neuro symptoms (rule out intracranial haemorrhage).

🩺 Management

• Acute Toxicity: ABCs first. Benzodiazepines (diazepam, lorazepam) for agitation, anxiety, tachycardia, hypertension, hyperthermia.
• Cardiovascular:
  • ✔️ Hypertension/tachycardia: benzodiazepines, nitrates, or CCBs.
  • 🚫 Beta-blockers: cause unopposed alpha-adrenergic vasoconstriction → worsening hypertension/vasospasm.
  • ✔️ Chest pain: IV nitrates, CCBs; PCI if STEMI develops.
• Hyperthermia: Active cooling, IV fluids, dantrolene if severe. Avoid phenothiazines/antipsychotics.
• Rhabdomyolysis: Aggressive IV fluids; monitor CK, renal function.
• Long-term:
  • Psychosocial rehab & addiction services.
  • Cardiovascular risk monitoring (↑ atherosclerosis risk).

📌 Exam Pearls

• Always ask about cocaine in chest pain, haemorrhagic stroke, or trauma (esp. fights/assaults).
• 🚫 Do not give beta-blockers alone → “unopposed alpha” hypertension crisis.
• Cocaine chest pain → treat with nitrates/CCBs, not thrombolysis unless PCI unavailable and STEMI confirmed.
• Hyperthermia + agitation → benzodiazepines are first-line.