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cardio.post-arrest.cocaine-related.v1

Post-cardiac-arrest care — cocaine-related arrest (sympathomimetic + Na-channel blockade)

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Phase E variant of cardio.post-arrest.core.v1 — cocaine-related arrest. Multi-mechanism arrest pathophysiology: sympathomimetic VF / pVT, Na-channel blockade (wide-QRS + Brugada-like patterns), accelerated atherothrombosis (cocaine ACS), and α-adrenergic crisis (vasospasm + HTN). Also screen for cocaine-induced dissection, ICH, mesenteric ischemia, hyperthermic rhabdomyolysis. Two pharmacologic anchors: BENZODIAZEPINE early (lorazepam 1-2 mg IV q5-15 min for sympathetic blunting — even during ACLS adjunct) per AHA 2008 PMID 18391116; SODIUM BICARBONATE 1-2 mEq/kg IV bolus for QRS >100 ms (Na-channel unblock; AHA 2010 toxicology PMID 20956224 + Lange NEJM 1989 PMID 2522592 mechanism). AVOID β-blocker monotherapy in active cocaine intoxication — unopposed α-stimulation worsens vasospasm + HTN crisis (Lange NEJM 1989 PMID 2522592 + AHA 2008 PMID 18391116 + ACC/AHA 2025 ACS Class III). Phentolamine pure α-blockade for refractory HTN; nitrate + non-DHP CCB for vasospastic ischemia. Aggressive cooling for hyperthermia >38.5 °C (cocaine + agitation + seizures + serotonergic concurrency) before standard TTM 32-36 °C × 24h. Naloxone if opioid co-ingestion (fentanyl-contaminated cocaine increasingly common). Long-term: ADDICTION MEDICINE primary engagement — contingency management is the highest-evidence behavioral intervention for stimulant-use disorder (Petry meta-analyses); naloxone rescue kit; mental health (PTSD + depression + suicide risk monitoring); harm-reduction counseling. ICD only if unmasked Brugada or persistent LVEF <35 on full GDMT at 90 d sustained abstinence. Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: persistent QRS widening despite bicarb, recurrent VF after inadvertent β-blocker, suicide attempt with co-ingestion, repeat cocaine arrest within hours-days, cocaine-induced dissection or ICH complicating arrest. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute Phase E wave 21.

Entry points (4)

  • symptom
    ROSC after cardiac arrest with documented or suspected cocaine intoxication — sympathetic crisis + Na-channel blockade arrest pattern
    rosc_after_cocaine_related_arrest
  • history
    Witnessed collapse in known cocaine user (recent insufflation, smoking, or IV use) — high pre-test probability sympathomimetic VF / pVT or cocaine ACS arrest
    witnessed_collapse_in_known_cocaine_user
  • history
    Cocaine user with agitated delirium + hyperthermia + seizure progressing to arrest — sympathetic crisis pattern; immediate benzodiazepine + cooling + bicarb-ready
    cocaine_user_with_agitation_hyperthermia_seizure_then_arrest
  • imaging
    Wide QRS (>100 ms) or Brugada-like pattern post-ROSC in suspected cocaine arrest — Na-channel blockade pattern; sodium bicarbonate now
    wide_qrs_or_brugada_pattern_post_rosc_in_suspected_cocaine_arrest

Required inputs (24)

  • agerequired
    demographic • used at CONTEXT
    Age informs reversibility, ICD-eligibility framing, and SUD treatment plan; mean cocaine-arrest age younger than ischemic-arrest cohorts
  • cocaine_use_history_route_timing_doserequired
    history • used at CONTEXT
    Route (insufflation / smoking / IV) + timing + dose informs duration of effect, peak risk window (insufflation peak 30 min, smoking 5-15 min, IV 1-2 min), and concurrent toxicity exposure
  • co_ingestion_history_opioid_alcohol_methamphetamine_serotonergicrequired
    history • used at CONTEXT
    Co-ingestion is the rule, not exception: opioids (need naloxone), alcohol (cocaethylene → prolonged toxicity), methamphetamine (synergistic sympathetic crisis), serotonergic agents (serotonin syndrome confounder)
  • witnessed_arrest_and_initial_rhythmrequired
    history • used at CONTEXT
    Witnessed + initial rhythm (VF/pVT > PEA > asystole) drives prognosis; sympathomimetic VF most common; PEA more common with concurrent hyperthermia / hypovolemia / acidosis
  • time_to_cpr_minrequired
    history • used at CONTEXT
    Bystander CPR within 1 min markedly improves outcome; CAHP/OHCA score input
  • time_to_defibrillation_minrequired
    history • used at CONTEXT
    AED within 3-5 min critical for shockable rhythms; cocaine-related arrest often shockable initially
  • prior_psychiatric_history_or_suicide_attemptrequired
    history • used at CONTEXT
    Cocaine intoxication arrest may overlap with suicide attempt (intentional overdose, co-ingestion) — drives mental health pathway + family meeting framing
  • sbprequired
    vital • used at TREATMENT
    Post-ROSC HTN crisis common from residual sympathetic surge; SBP guides α-blocker / nitrate / CCB selection (β-blocker monotherapy AVOIDED); SCAI staging if shock
  • core_temprequired
    vital • used at TREATMENT
    Hyperthermia (>38.5 °C) common with cocaine + agitation + seizures + serotonergic co-ingestion; aggressive active cooling first, then standard TTM 32-36 °C × 24h per TTM2 PMID 34133859
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia post-ROSC; SpO2 92-98% (AHA 2020 Class IIa)
  • ecg_12_lead_serial_with_qrs_qtc_brugada_patternrequired
    imaging • used at INITIAL_WORKUP
    12-lead ECG immediately post-ROSC + serial; QRS >100 ms triggers sodium bicarbonate; QTc prolongation common with cocaine + co-ingestion; Brugada-like pattern from Na-channel blockade resolves with bicarb; ST changes screen for cocaine-ACS confounder
  • echo_post_roscrequired
    imaging • used at INITIAL_WORKUP
    Echo for LVEF (cocaine cardiomyopathy + post-arrest stunning), wall-motion abnormalities (cocaine ACS), valvular vegetations (IVDU endocarditis screen), aortic root for dissection screen
  • cxr_post_cprrequired
    imaging • used at INITIAL_WORKUP
    CXR for rib fractures from CPR, pulmonary edema (cocaine-related ARDS / negative-pressure pulmonary edema after seizure), aspiration pneumonia, mediastinal widening (dissection screen)
  • ct_head_if_focal_or_persistent_coma
    imaging • used at BRANCHING_WORKUP
    Cocaine intoxication carries 7x risk of intracerebral hemorrhage from acute HTN crisis + cocaine vasculopathy; CT head if focal neuro deficit, persistent coma post-rewarm, or seizures
  • ct_chest_abdomen_with_contrast_if_dissection_or_mesenteric_suspicion
    imaging • used at BRANCHING_WORKUP
    CT angio if cocaine + chest pain + asymmetric pulses → dissection; CT abdomen if abdominal pain + lactate / acidosis disproportionate → mesenteric ischemia from cocaine-induced vasospasm
  • urine_drug_screen_immunoassay_plus_confirmatoryrequired
    lab • used at INITIAL_WORKUP
    Urine drug screen for cocaine metabolites (benzoylecgonine), opioids, methamphetamine, MDMA, PCP, cannabinoids, benzodiazepines (baseline before iatrogenic admin); benzoylecgonine detectable up to 3-5 d post-use
  • troponin_serialrequired
    lab • used at INITIAL_WORKUP
    Cocaine ACS occurs in 6% of cocaine chest-pain ED visits; serial troponin q3-6h × 24h to characterize ischemic substrate vs post-arrest stunning vs catecholamine cardiomyopathy
  • cpk_total_for_rhabdomyolysisrequired
    lab • used at INITIAL_WORKUP
    Cocaine + agitated delirium + hyperthermia + seizure → severe rhabdomyolysis; CK > 5000 demands aggressive volume + alkalinization; informs renal replacement decision
  • lactate_serialrequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + post-arrest perfusion debt + sympathetic-mediated hyperlactatemia; trajectory drives prognosis (SCAI 2022 PMID 35718438)
  • creatinine_serial_for_akirequired
    lab • used at CONTEXT
    Baseline + serial; AKI from rhabdomyolysis + post-arrest hypoperfusion + cocaine-induced renal vasospasm; KDIGO 2012 staging
  • electrolytes_extended_k_mg_ca_phosrequired
    lab • used at INITIAL_WORKUP
    Cocaine + sympathetic surge + bicarb therapy + rhabdomyolysis cause profound electrolyte derangement; K + Mg + Ca + Phos correction essential to stabilize myocardium
  • abg_with_lactate_and_anion_gaprequired
    lab • used at INITIAL_WORKUP
    ABG for acid-base status (lactic acidosis common); guides sodium bicarbonate dosing for QRS widening + acidosis correction
  • hcg_in_reproductive_age_female
    lab • used at CONTEXT
    Cocaine arrest in pregnancy → cross-link to peripartum-arrest engine; placental abruption risk
  • hiv_hcv_screen_if_ivdu_pattern
    lab • used at FOLLOWUP
    IV cocaine use → IVDU pattern; baseline HIV + HCV screening; informs endocarditis pretest probability

12-phase flow (12)

  1. 1FRAME
    Cocaine-related arrest = multi-mechanism (sympathomimetic VF / Na-channel-blockade wide-complex arrhythmia / coronary vasospasm / accelerated atherothrombosis); also screen for cocaine-induced dissection, ICH, mesenteric ischemia. Two pharmacologic anchors: BENZODIAZEPINE early (even during ACLS) + SODIUM BICARBONATE 1-2 mEq/kg IV for QRS >100 ms. AVOID β-blocker monotherapy. Route to parent post-arrest core for TTM + neuroprog.
    inputs: cocaine_use_history_route_timing_dose, witnessed_arrest_and_initial_rhythm
    advance: cocaine etiology + multi-mechanism differential framed
  2. 2ENTRY
    Standard ACLS for index arrest WITH cocaine-specific modifications: lorazepam 1-2 mg IV early (sympathetic blunting), sodium bicarbonate 1-2 mEq/kg IV bolus if wide QRS or refractory VF, AVOID β-blocker monotherapy; aggressive active cooling for hyperthermia; activate cardiology + toxicology + addiction medicine consults
    inputs: age, witnessed_arrest_and_initial_rhythm, time_to_cpr_min, time_to_defibrillation_min
    advance: ACLS with cocaine modifications + transport to CICU initiated
  3. 3CONTEXT
    Cocaine route + timing + dose, co-ingestion (opioids → naloxone, alcohol → cocaethylene, methamphetamine, serotonergics), prior psychiatric history, suicide attempt screening, family / scene witnesses for incident reconstruction
    inputs: co_ingestion_history_opioid_alcohol_methamphetamine_serotonergic, prior_psychiatric_history_or_suicide_attempt, sbp, core_temp, spo2, creatinine_serial_for_aki
    advance: context complete + GOC + family + addiction-medicine handoff documented
  4. 4RED_FLAGS
    Refractory wide-QRS VF/pVT despite bicarb → ECPR consideration (ARREST PMID 33308475); persistent QRS >150 ms refractory to repeat bicarb → consider lipid emulsion as salvage; suspected aortic dissection (chest pain + asymmetric pulses) → emergent CTA; acute neurologic deficit or persistent coma → CT head for ICH; severe hyperthermia >40 °C → ICE + paralysis if needed
    inputs: sbp, ecg_12_lead_serial_with_qrs_qtc_brugada_pattern, core_temp
    actions: cardiogenic_shock
    advance: multi-organ red flags screened + escalations triggered
  5. 5INITIAL_WORKUP
    12-lead ECG (QRS, QTc, Brugada-pattern, ST), serial troponin, CK total + LDH (rhabdo), urine drug screen, BMP + extended electrolytes (K, Mg, Ca, Phos), ABG with lactate, CBC, coags, type-and-screen, LFTs, CXR, bedside echo (LVEF, vegetations, aortic root, dissection screen), serial neuro exam
    inputs: ecg_12_lead_serial_with_qrs_qtc_brugada_pattern, echo_post_rosc, cxr_post_cpr, urine_drug_screen_immunoassay_plus_confirmatory, troponin_serial, cpk_total_for_rhabdomyolysis, lactate_serial, electrolytes_extended_k_mg_ca_phos, abg_with_lactate_and_anion_gap
    actions: post_arrest_care, cocaine_chest_pain, panel.cardiac, panel.renal, panel.abg
    advance: workup documented + cocaine-mechanism differential characterized
  6. 6BRANCHING_WORKUP
    STEMI on post-ROSC ECG → cath (cocaine ACS pattern, often plaque rupture or vasospasm); CT angio chest if dissection suspicion; CT head if neuro deficit / persistent coma → ICH from acute HTN crisis (cocaine vasculopathy); CT abdomen if mesenteric ischemia signs; recurrent VT/VF after rewarm → EP + channelopathy workup (cocaine may unmask Brugada substrate); endocarditis workup if IVDU + fever / vegetations on echo
    inputs: ct_head_if_focal_or_persistent_coma, ct_chest_abdomen_with_contrast_if_dissection_or_mesenteric_suspicion
    actions: acs_pathway, wide_complex_tach, acute_pulm_edema
    advance: multi-organ branching decision made
  7. 7DIFFERENTIAL
    Pure cocaine arrest (sympathomimetic VF + Na-blockade) vs cocaine ACS arrest vs cocaine-induced dissection arrest vs cocaine ICH arrest vs unmasked underlying disease (Brugada, LQTS) vs concurrent opioid overdose (need naloxone) vs polysubstance / suicide attempt — drives long-term plan
    inputs: urine_drug_screen_immunoassay_plus_confirmatory, co_ingestion_history_opioid_alcohol_methamphetamine_serotonergic
    advance: mechanism narrowed + co-ingestion characterized
  8. 8RISK_STRATIFICATION
    CAHP / OHCA scores apply; SCAI shock stage; HEART score for cocaine ACS sub-component; CKD-EPI for renal-adjustment; CHA2DS2-VASc if AF detected
    inputs: witnessed_arrest_and_initial_rhythm, time_to_cpr_min, time_to_defibrillation_min, sbp, lactate_serial
    actions: calc.map, calc.heart, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: risk class + secondary-mechanism status documented
  9. 9TREATMENT
    COCAINE-SPECIFIC: lorazepam 1-2 mg IV q5-15 min titrate sympathetic blunting; sodium bicarbonate 1-2 mEq/kg IV bolus for QRS >100 ms or recurrent wide-QRS arrhythmia; AVOID β-blocker monotherapy (Lange NEJM 1989 + AHA 2008 + ACC/AHA 2025 ACS Class III); for vasospastic HTN/ischemia → nitroglycerin + diltiazem or verapamil + phentolamine α-blockade. STANDARD POST-ROSC: norepinephrine for MAP ≥65 (cocaine wears off → vasoplegia possible), TTM 32-36 °C × 24h once normothermic post-cooling, lung-protective ventilation, sedation. NALOXONE if opioid co-ingestion + respiratory depression. AGGRESSIVE COOLING for hyperthermia >38.5 °C (ICE + paralysis if refractory). MAGNESIUM for TdP from QTc prolongation. RHABDO MGMT: aggressive crystalloid (urine output ≥1-2 mL/kg/h), bicarb infusion if myoglobinuric AKI. GDMT initiated once stable if cocaine cardiomyopathy / post-arrest LVEF reduced.
    inputs: sbp, core_temp, spo2, creatinine_serial_for_aki
    actions: protocol.cardiogenic_shock
    advance: cocaine-specific resuscitation + standard post-ROSC bundle delivered + addiction medicine engaged
  10. 10DISPOSITION
    CICU for hemodynamic monitoring + telemetry + cooling; floor only after 48h of telemetry without recurrent arrhythmia + bicarb-corrected QRS + stable mental status
    advance: unit + service-line ownership + addiction medicine + mental health consults assigned
  11. 11MONITORING
    Continuous telemetry × 48h (cocaine + metabolites have prolonged arrhythmogenic effect; bicarb-induced QRS narrowing may rebound); serial ECG q4-6h × 24h with QRS + QTc; serial troponin q3-6h × 24h; multimodal neuroprog ≥72h post-rewarm (Sandroni 2021 PMID 33745427); BMP + extended electrolytes q6h; CK trend until <1000; lactate q2-4h until normalized; UDS confirmatory at 24-48h
    inputs: ecg_12_lead_serial_with_qrs_qtc_brugada_pattern
    actions: panel.cardiac
    advance: monitoring + neuroprog timeline documented
  12. 12FOLLOWUP
    Cardiology follow-up at 2-4 weeks: echo for LVEF (cocaine cardiomyopathy reversibility with sustained abstinence); EP follow-up if Brugada-like ECG persisted post-bicarb (genuine Brugada channelopathy unmasked vs cocaine-induced); ADDICTION MEDICINE primary follow-up: contingency-management program enrollment (highest-evidence behavioral intervention for stimulant-use disorder per Petry meta-analyses), naloxone rescue kit for opioid co-ingestion risk, mental health PTSD/depression workup, hep C / HIV testing if IVDU pattern; family CPR + AED training; if pregnancy → OB / NICU pathway
    inputs: hiv_hcv_screen_if_ivdu_pattern
    advance: cardiology + EP + addiction medicine + mental health + family CPR pathway booked