Toxicology

Potent sympathetic nervous system stimulant

Inhibits the presynaptic reuptake of epinephrine and norepinephrine; also stimulates norepinephrine

release

Acts as a reuptake inhibitor of dopamine, norepinephrine, and serotonin

Predominantly euphoria or excited delirium

Common/severe adverse effects include:

Psychiatric: Agitation, anxiety, psychosis, delirium

ii.

Neurologic: Stroke, subarachnoid or intracranial hemorrhage, seizures

iii.

Cardiovascular: Tachycardia, hypertension, palpitations, arrhythmias, heart failure, aortic

dissection

iv.

GI: Gastric ulcers, gastric perforation, bowel ischemia

Respiratory: Status asthmaticus, pulmonary hypertension, pulmonary edema, alveolar

hemorrhage

vi.

Renal: Acute kidney injury, rhabdomyolysis

Treatment

Mostly supportive care with intravenous fluid administration

Gastric decontamination is typically not recommended. Activated charcoal may provide benefit if

given within 1 hour of oral ingestion.

Benzodiazepines are administered for agitation or seizure activity and titrated to relaxation.

Because of their ability to block the CNS stimulant effect of cocaine, benzodiazepines are also an

effective treatment for hypertension and tachycardia.

nicardipine). Although controversial and devoid of robust empirical evidence, it has been

recommended to avoid the use of ϐ-receptor blocking agents because of a risk of unopposed

α-receptor activity leading to an increase in blood pressure.

Mechanism of action/toxicity: increases presynaptic concentrations of serotonin, dopamine, and

2014;34:745-57)

Predominantly euphoria, increased energy, and alertness

Common adverse effects include:

Psychiatric: Agitation, aggression, anxiety, hallucinations, paranoia

ii.

Neurologic: Amnesia, confusion, insomnia, seizures, dizziness, headache

iii.

Cardiovascular: Angina, hypertension, tachycardia, palpitations

iv.

GI: Abdominal pain, nausea, vomiting, anorexia, hepatic failure

Renal: Acute kidney injury, increased SCr, and rhabdomyolysis

Treatment

Mostly supportive care with intravenous fluid administration

Benzodiazepines or antipsychotics for agitation or anxiety

Haloperidol is an alternative option, but it should be used with caution and close monitoring

because of the potential to worsen hyperthermia.

ii.

Consider propofol or dexmedetomidine for severe symptoms.

Antiemetics for nausea and vomiting