Key messages

• The mainstays of therapy for cocaine toxicity are sedation with benzodiazepines and rapid cooling; the use of phenothiazines or butyrophenones for sedation should be avoided.

• Chest pain should be treated with oxygen, nitroglycerin (glyceryl trinitrate), and aspirin as usual, but benzodiazepines with their proven efficacy to treat sympathetic excess should substitute for b-adrenergic antagonists which increase myocardial oxygen demand and decrease myocardial perfusion.

• Refractory chest pain and hypertension may be treated with phentolamine to reduce coronary vasospasm and afterload.

• Calcium-channel blockers should be avoided.

• Sodium bicarbonate is the drug of choice for treating wide-complex dysrhythmias and ongoing rhabdomyolysis. Introduction

Cocaine is a highly addictive drug which has become readily affordable; its abuse has increased 10- to 20-fold in the United States over a recent decade. By 1990, over 40 per cent of all drug-related fatalities were due to cocaine ( National Ins.tjlMt§ oD.Diy.O.AbMs.e l990). Diagnosis, assessment, and management of acute toxicity, particularly agitated delirium and ischemic events, have become increasingly important to the critical care physician.

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