CURRENT Essentials of Critical Care.pdf

230 Current Essentials of Critical Care■■■CocaineEssentials of Diagnosis• Tachycardia, hypertension, hyperthermia, agitation, and seizures• Cardiac dysrhythmias, including atrial fibrillation or tachycardia,ventricular tachycardia, or asystole• End-organ ischemia can cause stroke, myocardial infarction,bowel ischemia, renal infarction, limb ischemia; severe hypertensioncan lead to intracranial hemorrhage (subarachnoid or intraparenchymal)or aortic dissection• Pneumothorax or pneumomediastinum can be seen when cocainesmoked or snorted• Excess muscle activity can lead to rhabdomyolysis or hyperthermia• Can be used by snorting, smoking, or intravenous injectionDifferential Diagnosis• Sympathomimetic, theophylline, phencyclidine intoxication• Ethanol or benzodiazepine withdrawal• Thyrotoxicosis• CNS infectionTreatment• Supportive care• Active cooling measures for hyperthermia• Benzodiazepines for agitation and seizures• Phenobarbital or phenytoin for seizures refractory to benzodiazepines• Intravenous nitroprusside for severe hypertension• If myocardial ischemia or infarction, usual therapy except avoidbeta blockers because of potential for severe hypertension fromunopposed alpha-adrenergic stimulation; phentolamine may beused for coronary vasospasm• Intravenous fluids and alkalinization of urine for rhabdomyolysis■ PearlLidocaine is often ineffective for cocaine-induced ventricular dysrhythmias;consider cocaine toxicity in a young otherwise healthy patientin an agitated state with ventricular dysrhythmia unresponsiveto lidocaine.ReferenceShanti CM, Lucas CE: Cocaine and the critical care challenge. Crit Care Med2003;31:1851. [PMID: 12794430]