special subjects
Cocaine
Treatment ofCocaineIntoxication
IV benzodiazepines Avoidance of beta-blockers Cooling for hyperthermia as needed if any powder is left in nares. Body Packing and Body Stuffing may need gastrointestinal decontamination or even surgical removal. may be needed. Occasionally, severely agitated patients must be pharmacologically paralyzed and mechanically ventilated to ameliorate Rhabdomyolysis , Hypertension that does not respond to benzodiazepines is treated with IV nitrates (eg,nitroprusside),nicardipine, or alpha-adrenergic antagonist (eg,phentolamine); beta-blockers are not recommended because they allow continued alpha-adrenergic stimulation. Hyperthermia can be life threatening and should be managed aggressively with sedation plus evaporative cooling, ice packs, and maintenance of intravascular volume and urine flow with IV normal saline solution. Phenothiazines are not used for sedation because they lower seizure threshold, and their anticholinergic effects can interfere with cooling. Cocaine-related chest pain is evaluated as for any other patient with potential myocardial ischemia or aortic dissection, with chest x-ray, serial ECG, and serum cardiac markers. As discussed, beta-blockers are contraindicated, and benzodiazepines are a first-line drug. If coronary vasodilation is required after benzodiazepines are given, nitrates are used, orphentolamine1 to 5 mg IV given slowly can be considered. Beta blockers and type Ia and Ic antiarrhythmics should be avoided for the treatment ofcocaine-induced arrhythmias. Heavycocaineusers and people who inject the drug IV or smoke it are most likely to become dependent. Light users and people who take the drug nasally or orally are at lower risk of becoming dependent. Stopping sustained use requires considerable assistance, and the depression that may result requires close supervision and treatment. Many outpatient therapies, including support and self-help groups andcocainehotlines, exist. Inpatient therapy is used primarily when it is required for serious physical or mental comorbidity or when outpatient therapy has repeatedly been unsuccessful. -addicted mothers, see Prenatal Drug Exposure . 