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Three Part Question

In [the general population of patients] with cocaine induced arrhythmias], what is the [best treatment for cocaine induced arrhythmias].

Clinical Scenario

A 19 year old male who has been using crack cocaine for the past few days presents to the emergency room with chest pain and a wide complex tachycardia. He is quite agitated, hypertensive and uncooperative. You know that benzodiazepines are the recommended drugs for cocaine overdose, but what is the best medical treatment for cocaine induced arrhythmias.

Search Strategy

Medline 1946-10/12 using OVID interface, Cochrane Library (2012), PubMed clinical queries
[(exp cardiac arrhythmias) AND (exp cocaine OR cocaine.mp OR exp cocaine-related disorders OR exp crack cocaine)]. Limit to English language, humans.

Search Outcome

194 papers were identified; there were no clinical studies relevant to the clinical question.

Comment(s)

Patients with cocaine toxicity and cocaine induced arrhythmias can be difficult to treat due to the complex mechanisms involved with the generation of the arrhythmias. Arrhythmias can be induced via sodium channel blockade, potassium channel blockade, catecholamine excess, myocardial ischemia or infarction, or a combination of any or all of the causes listed. Although no clinical studies have been done to support any one particular therapy, it is best to approach these arrhythmias with simple supportive care that includes sedation, oxygenation, volume resuscitation, and correction of any electrolyte abnormalities. Subsequent therapy should be tailored to treating the presenting arrhythmia. The use of beta adrenergic agonists and both types IA and IC anti arrhythmic agents is contraindicated as well as mixed alpha and beta adrenergic antagonists. Wide complex tachycardias can be treated with hypertonic sodium bicarbonate and QT prolongation can be initially treated with magnesium. Re-entrant ventricular arrhythmias can be treated safely with lidocaine. These patients should be pretreated with benzodiazepines. All patients with cocaine-induced arrhythmias should be admitted until their arrhythmias resolve and they are stable.

Clinical Bottom Line

Patients who use cocaine can present with a variety of arrhythmias. These can include wide QRS tachycardia, prolonged QT intervals, re-enterant tachycardias, and arrhythmias in the presence of ischemic changes. While there have been no studies giving direct evidence to support a particular therapy for these arrhythmias, a common sense approach to treating arrhythmias is recommended. This approach includes sedation, oxygenation, volume resuscitation, electrolyte correction, and therapies tailored to the presenting arrhythmia.