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ACUTE EXPOSURE INFORMATION
- USES: Cocaine is used as a topical vasoconstrictor for otolaryngology procedures. The most common clinical scenario with cocaine involves abuse for its psychostimulant effects.
- PHARMACOLOGY: The psychostimulant effects of cocaine are due to blockade of reuptake of monoamine (dopamine, norepinephrine, and serotonin) in CNS neurons. The net effect is CNS excitation and an increase in sympathetic nervous system activity. Decreased reuptake of norepinephrine may cause vasoconstriction. The direct cardiac effects of cocaine are due to antagonism of voltage-gated sodium channels in cardiomyocytes.
- TOXICOLOGY: Increased sympathetic activity may cause hallucinations, seizures, hypertension, and agitation. Vasospasm may cause cerebral or cardiac ischemia and may contribute to hypertension. These effects may occur with recreational doses of cocaine. Cardiac sodium channel antagonism only occurs with cocaine overdose and will delay intra-cardiac conduction, causing decreased myocardial function and triggering dysrhythmias. Absorption occurs after injection, ingestion, insufflation, or topical application.
- EPIDEMIOLOGY: Cocaine use is common. Cocaine intoxication is frequently associated with emergency department presentation for related complaints (chest pain) or indirectly related complaints (trauma). Severe toxicity is less common. Body stuffers (patients who rapidly ingest small to moderate amounts of cocaine in an attempt to avoid arrest) are common. Body packers (patients who ingest large quantities of cocaine in an attempt to smuggle the cocaine for later distribution) are occasionally seen in locations where international travel is common.
- WITH POISONING/EXPOSURE
- MILD TO MODERATE TOXICITY: Patients may develop anxiety, hallucinations, chest pain, hypertension, palpitations, or agitation. In some cases, recreational doses of cocaine may cause cardiac or cerebral ischemia.
- SEVERE TOXICITY: Patients with severe toxicity may present with either seizures or severe agitation. If uncontrolled, this may progress to severe hyperthermia, rhabdomyolysis, acute renal failure, hepatic injury, coagulopathy, and decreased myocardial function. Severe intoxication may progress rapidly to dysrhythmias and cardiovascular collapse.
- ROUTES OF ADMINISTRATION (eg, intranasal, oral, rectal, IV, inhaled, or intravaginal) have been associated with clinical toxicity.
- Effects usually develop quickly (within a few minutes to an hour) and are of short duration, although delayed, prolonged effects have been reported after rupture of cocaine-filled condoms in the gastrointestinal tract.
- LEVAMISOLE ADULTERATION: A large percentage of cocaine bulk shipments entering the United States have been found to be adulterated with levamisole. Multiple cases of levamisole toxicity (eg, agranulocytosis, neutropenia, vasculitis, retiform purpura) have been reported in patients using cocaine adulterated with levamisole. Refer to the LEVAMISOLE management for further information.
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