This handout is for cocaine / sympathomimetic hypertensive crisis (alpha-driven htn + tachycardia + coronary vasospasm). Your care team identified this based on: cocaine, methamphetamine, mdma, or sympathomimetic use within 24-72 h + sbp ≥180 / dbp ≥120 (aha 2008 pmid 18391116; hollander nejm 2008 pmid 18172180).
Other reasons your team may use this plan: hypertensive crisis + tachycardia + diaphoresis + agitation + dilated pupils + chest pain — sympathomimetic toxidrome; ecg ischemia/stemi pattern in setting of acute cocaine/stimulant use — cocaine-associated acs pathway.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| lorazepam | 1-2 mg IV q5-10 min PRN, max 8 mg in 1 h | IV | PRN | AHA 2008 Class I PMID 18391116 — benzodiazepine first for sympatholysis (reduces HTN + tachy + agitation); diazepam alternative; titrate to symptom control |
| diazepam | 5-10 mg IV q5-10 min | IV | PRN | AHA 2008 — alternative to lorazepam; longer half-life advantageous for sustained sympatholysis |
| nitroglycerin | 5-200 mcg/min IV titrate q3-5 min | IV | continuous | AHA 2008 Class IIa — vasodilator + coronary vasodilator; reverses cocaine coronary vasoconstriction; preferred over β-blocker |
| phentolamine | 1-5 mg IV q5-15 min titrate | IV | PRN bolus | Boehrer Am J Med 1993 PMID 8390052 — pure alpha-blocker reverses cocaine alpha-vasoconstriction + reverses coronary vasospasm; AHA 2008 Class IIa |
| verapamil | 5-10 mg IV slow push q15-30 min OR 0.075-0.15 mg/kg | IV | PRN bolus | Negus Circulation 1994 — verapamil reverses cocaine coronary vasospasm; AHA 2008 Class IIa CCB acceptable |
| diltiazem | 0.25 mg/kg IV bolus then 5-15 mg/h infusion | IV | continuous | AHA 2008 — alternative non-DHP CCB; useful if AF + RVR |
| labetalol | AVOID as first-line; if used: 10-20 mg IV q10 min | IV | bolus | AHA 2008 — labetalol is debated; mixed α/β theoretically OK but small case reports of paradoxical HTN; AVOID as first-line; reasonable as add-on if benzo + NTG + phentolamine inadequate |
| AVOID metoprolol/esmolol/propranolol | AVOID | N/A | N/A | Lange NEJM 1989 PMID 2522592 — propranolol potentiates cocaine coronary vasoconstriction (unopposed alpha); AHA 2008 Class III; ACC/AHA 2025 ACS Class III β-blocker monotherapy in cocaine ACS |
| AVOID succinylcholine if rhabdomyolysis | AVOID | N/A | N/A | Hyperkalemia from rhabdomyolysis + succinylcholine = arrest risk; use rocuronium for RSI |
Plan: Cocaine / sympathomimetic HTN crisis — benzodiazepine-first sympatholysis; AVOID β-blocker monotherapy (unopposed alpha); phentolamine reverses alpha-vasoconstriction
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Substance use disorder counseling + treatment (matrix model for stimulant, contingency management evidence-based per Stitzer 2010); cardiology follow-up if MI occurred (high-risk for recurrent cocaine-MI); echo if Takotsubo suspected (cocaine is precipitant); BP regimen if persistent HTN; opioid agonist therapy if fentanyl-laced supply suspected; harm reduction
Guideline: AHA 2008 Cocaine Cardiovascular Complications Scientific Statement (McCord PMID 18391116) + 2025 ACC/AHA ACS Guideline (Class III β-blocker monotherapy) + 2025 ACC/AHA HTN (Whelton)