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hyperactive reflexes, talkativeness, irritability, weakness, insomnia, and fever. In
addition, confusion, anxiety, delirium, paranoid hallucinations, panic states, and
suicidal or homicidal tendencies can occur, especially in patients who have
underlying mental illnesses. However, these psychotic effects may occur in
anyone who chronically abuses amphetamines. Cardiotoxic effects include
palpitations, anginal pain, and rarely, hypertensive crisis or circulatory collapse.
GI effects include anorexia, nausea, vomiting, diarrhea, and abdominal cramps.
Severe overdoses may cause convulsions, coma, and cerebrovascular accidents.
Both psychological and physical dependence occurs with chronic use. Chronic
amphetamine abuse causes symptoms similar to many of those seen after acute
overdose. The most common serious effect is a psychotic reaction with vivid
hallucinations and paranoid delusions, often mistaken for schizophrenia.
Recovery may not occur after withdrawal of the drug. In patients with persistent
psychotic symptoms, it has been theorized that the amphetamine has hastened the
onset of incipient schizophrenia. Chronic amphetamine abuse is also associated
with the development of cerebral vasculitis.
In addition to the sympathomimetic features noted above, unique features of
MDMA toxicity may include hyponatremia, serotonin syndrome, and
hepatotoxicity.
Consider GI decontamination for treatment of intoxication after ingestion. For
severe agitation, use a benzodiazepine or haloperidol (0.01 to 0.05 mg/kg IM).
Severe hypertension unresponsive to benzodiazepines may require such agents as
phentolamine, hydralazine, or IV sodium nitroprusside. Provide ample IV fluids
to promote urinary excretion.

Cocaine
CLINICAL PEARLS
In addition to stimulant effects, cocaine is a Type Ib antidysrhythmic
with cardiac sodium channel blocking activity. Toxicity may include EKG
abnormalities, seizures, and dysrhythmias.
Cocaine toxicity can lead to myocardial ischemia.

Current Evidence
Cocaine occurs in the leaves of Erythroxylum coca and other species of
Erythroxylum trees indigenous to Peru and Bolivia, where the leaves have been
used for centuries by the natives to increase endurance and to promote a sense of