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Cocaine also causes other syndromes of organ dysfunction, including
hyperpyrexia and renal failure. Coke fever (or pyrexia ) is a common occurrence
after acute cocaine use. It is often associated with muscle rigidity (resembling
neuroleptic malignant syndrome) or rhabdomyolysis (the result of agitation
and/or physical restraint). Rhabdomyolysis may result in subsequent
myoglobinuric renal failure. Recent reports of cocaine adulterated with
levamisole, a veterinary antihelminth that potentiates cocaine’s euphoric effects,
describe patients presenting with fever and reversible agranulocytosis.
Infants exposed to cocaine may also exhibit CNS excitation that includes
hyperactivity, dystonic posturing, altered mental status, or frank seizures.
Because of the high risk of mortality, cocaine intoxication requires rapid,
thorough assessment and management. Immediate attention should be paid to the
vital signs, including core temperature. The patient who develops seizures
requires immediate airway control as well as anticonvulsant therapy.
Benzodiazepines are considered the anticonvulsants of choice because of their
rapid onset of action and because animal data have demonstrated decreased
mortality with their use for seizures from cocaine intoxication. Benzodiazepines
should also be administered liberally to the patient with mild to moderate toxicity
(agitation, hypertension, tachycardia) because of their efficacy in reversing many
of these clinical manifestations.
Because circulatory function can range from hypertensive crisis to
cardiovascular collapse, early vascular access is important. Anticipate blood
pressure instability and treat accordingly. For treatment of hypertensive crises,
liberal benzodiazepine use may be combined with a short-acting antihypertensive
(e.g., nitroprusside). Immediate treatment of hypertension is recommended
because it may lead to cerebrovascular or myocardial injury, although the use of
IV BBs alone is contraindicated. Treat dysrhythmias according to advanced
cardiac life support protocols (see Chapter 9 Cardiopulmonary Resuscitation ).
Treat hyperthermia promptly to prevent complications. Management is
discussed in Chapter 90 Environmental Emergencies, Radiological Emergencies,
Bites and Stings . Use IV fluids aggressively if there is myoglobinuria.

Patients with CNS depression or a lateralizing neurologic examination should
receive head imaging to rule out an intracranial vascular event.
Because cocaine is rarely ingested, the need for GI decontamination is confined
to body packers/stuffers or when drug coingestion is suspected. With body
stuffers, because bag leakage can lead to abrupt onset of severe intoxication and
possibly death, activated charcoal should be administered immediately. Gastric
emptying maneuvers and endoscopic removal of cocaine bags are relatively