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. 2008 Dec;4(4):277–283. doi: 10.1007/BF03161213

Case files of the Medical Toxicology Fellowship at the Toxikon Consortium in Chicago: Cocaine-associated wide-complex dysrhythmias and cardiac arrest— treatment nuances and controversies

Ejaaz A Kalimullah 1,2, Sean M Bryant 1,2,✉
PMCID: PMC3550110  PMID: 19031381

Conclusion

Manifestations of cocaine poisoning range widely from mild sympathomimetic overdrive to life-threatening seizures, hyperthermia, and cardiac dysrhythmias. While supportive care, including the judicious use of benzodiazepines and cooling measures, is paramount, the management of cocaine-associated wide-complex dysrhythmias and cardiac arrest regularly includes sodium bicarbonate boluses in order to narrow QRS length. When confronted with refractory dysrhythmias, one must weigh the benefits and risks of further antidysrhythmic therapies. Lidocaine is frequently recommended when sodium bicarbonate fails. While animal studies regularly demonstrate CNS toxicity (seizures) and variable effects on mortality with the use of lidocaine, it has demonstrated effectiveness in suppressing cardiotoxicity associated with cocaine poisoning [22–27]. While experience with using lidocaine may exist, literature support of its use in the patient with cocaineinduced wide-complex dysrhythmias is sparse at best [15,28]. Amiodarone has not been proven to be a viable alternative to sodium bicarbonate or lidocaine, possesses promiscuous pharmacological activity, and cannot be generally recommended for cocaine-associated dysrhythmias in the absence of data supporting its safety and efficacy [1,30].

Remembering Paracelsus’s words that all things are poisons certainly includes the current “evidence-based” antidotal therapy utilized to manage poisonings. Picking your poison (i.e., drug) to manage severe cocaine-induced cardiotoxicity may not be as straightforward as some would believe.

Keywords: cocaine, lidocaine, dysrhythmia, seizure, cardiac arrest

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Footnotes

There was no outside funding of any kind used for this study.

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