Cocaine

 

 

Considerations

 

  • Emergency/full stomach

  • Uncooperative/co-ingestions/agitated

  • Multisytem effects:

    • Airway: nasal septal necrosis

    • CNS: CVA/ICH, seizure, agitation, uncooperative, ↑MAC

    • Cardiovascular: 

      • HTN, tachycardia 

      • Arrhythmias

      • Coronary vasospasm resulting in angina or MI 

      • Cardiomyopathy

      • Aortic dissection

      • Unopposed alpha with beta blockade

    • Respiratory: 

      • RLD: crack lung, aspiration 

      • Pneumothorax, pneumomediastinum

      • Bronchospasm

    • Hematologic: DIC, thrombocytopenia

    • Renal: renal infarction, rhabdomyolysis

    • GI: ischemia, ulceration, perforation

 

 

Conflicts 

 

  • Difficult airway in an uncooperative patient

  • RSI in a patient with hemodynamic instability

  • Regional anesthesia in an uncooperative patient or coagulopathy 

  • Placental abruption, uncooperative OB patient, difficult airway

 

 

Anesthetic Management 

 

  • Delay OR if possible to optimize & allow for effects of cocaine to wane 

  • Monitor in high acuity setting/ICU

  • Full CAS monitors, 5 lead ECG & arterial line 

  • Treat adrenergic crisis & uncooperative status with benzodiazepines as first line 

  • Chest pain management: 

    • Consult cardiology urgently & keep broad ddx  

    • Start with midazolam

    • Consider NTG & phentolamine (1-2.5 mg q 5-15 minutes)

    • Avoid beta blockers 

  • If need for urgent GA:

    • Pre-induction arterial line 

    • Treat adrenergic tone as above 

    • Deep titrated GA, avoid ketamine, accept aspiration risk 

  • Wide complex tachycardia: NaHCO3 1-2 meq/kg until hemodynamic stability & QRS <120 ms

  • Postoperative discharge to high acuity/ICU  

 

 

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