Mon25October0844PM 18

A 35-year-old business man presents with anxiety and palpitations after 'snorting' cocaine. The patient denies any prior use and has also consumed some alcohol.

On examination, he is distressed and sweating with a temperature of 38°C, pulse of 138 beats per minute (regular) and a blood pressure of 216/110 mmHg. His ECG reveals a sinus tachycardia.

Which of the following is the most appropriate initial treatment for this man?

(Please select 1 option)

Lidocaine

Dantrolene

Verapamil

Propranolol

Diazepam Correct

Explanation

Cocaine abuse is quite common and neurological and cardiovascular side effects predominate.

Delirium, hyperthermia, arrhythmias, myocardial and cerebral infarction are reported.

In this patient, the first consideration should be to establish adequate ventilation and support the circulation, and also to remove any residual cocaine from the nostrils.

Generally, the toxic effects of cocaine are short-lived and relate to sympathetic stimulation, as in this case with tachycardia, pyrexia and hypertension.

Initial treatment of cocaine poisoning involves intravenous administration of diazepam to control agitation, and cooling measures for hyperthermia.

Sedation with diazepam may also be appropriate initial therapy for hypertension and tachycardia in this situation since the excessive sympathetic tone is largely centrally mediated.

Control of anxiety and agitation with diazepam when combined with rapid cooling may also decrease heat production in hyperthermic patients.

If further treatment is required, an intravenous nitrate is particularly useful for associated coronary artery spasm.