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Cocaine is a natural alkaloid derived from the leaves of Erythroxylum coca. Cocaine hydrochloride (powder cocaine) is a crystalline white powder. “Crack,” the free-base of cocaine hydrochloride, is an off-white substance named both for its rock-like appearance (“rock”) and the sound it makes when heated. “Crack” may be smoked as it vaporizes when heated. Inhalation of the vapor results in rapid absorption and distribution of the cocaine to the brain.
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Cocaine intoxication manifests as a sympathomimetic toxidrome, with tachycardia, hypertension, diaphoresis, mydriasis, delirium, and hyperthermia. Increased muscular activity may result in rhabdomyolysis. Numerous neurologic complications have been reported after cocaine use, including subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction, and seizures.
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Cardiovascular toxicity, including acute myocardial infarction, is well described after cocaine use. Dysrhythmias, including supraventricular tachycardia, atrial fibrillation and flutter, ventricular tachycardia, ventricular fibrillation, and torsades de pointes, have been reported. Cocaine is a sodium channel blocker and may cause QRS widening on the electrocardiogram (ECG). Aortic dissection and rupture have been associated with cocaine use.
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Pulmonary complications include pneumothorax, pneumomediastinum, and cardiogenic and noncardiogenic pulmonary edema (NCPE). “Crack lung” refers to an acute pulmonary syndrome of dyspnea, hypoxia, and diffuse pulmonary alveolar infiltrates.
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Management and Disposition
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Treatment is primarily supportive and focuses on the signs and symptoms of toxicity. Cardiac monitoring is indicated for symptomatic patients. Initial management focuses on control of agitation, reduction of the ...