This handout is for post-cardiac-arrest care — cocaine-related arrest (sympathomimetic + na-channel blockade). Your care team identified this based on: rosc after cardiac arrest with documented or suspected cocaine intoxication — sympathetic crisis + na-channel blockade arrest pattern.
Other reasons your team may use this plan: witnessed collapse in known cocaine user (recent insufflation, smoking, or iv use) — high pre-test probability sympathomimetic vf / pvt or cocaine acs arrest; cocaine user with agitated delirium + hyperthermia + seizure progressing to arrest — sympathetic crisis pattern; immediate benzodiazepine + cooling + bicarb-ready; wide qrs (>100 ms) or brugada-like pattern post-rosc in suspected cocaine arrest — na-channel blockade pattern; sodium bicarbonate now.
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 q5-15 min titrate sympathetic blunting + agitation + seizure | IV | titrated to effect | AHA 2008 cocaine PMID 18391116 — benzodiazepine first-line for cocaine-related cardiovascular toxicity; central sympathetic blunting reduces vasospasm + ischemia + HTN + agitation; consider during ACLS for adjunct sympathetic component |
| sodium bicarbonate | 1-2 mEq/kg IV bolus then 150 mEq in 1 L D5W infusion to maintain pH 7.45-7.55 | IV | bolus + infusion | AHA 2010 toxicology PMID 20956224 + Lange NEJM 1989 PMID 2522592 — Na load + alkalinization overcomes cocaine Na-channel blockade; analogous to TCA-overdose bicarb pathway |
| epinephrine | 1 mg IV q3-5 min during arrest | IV | standard ACLS | AHA 2020 ACLS standard; cocaine arrest does not contraindicate ACLS epinephrine despite sympathomimetic concern (mortality benefit dominates) |
| amiodarone | 300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h | IV | standard ACLS dosing | AHA 2020 ACLS Class IIb; preferred over lidocaine in cocaine arrest given Na-channel blockade contribution (lidocaine theoretically additive but evidence sparse — may use as second-line) |
| norepinephrine | 0.05-0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382; first-line vasopressor; cocaine effect wears off → vasoplegia possible despite initial hypertensive crisis |
| nitroglycerin | 0.4 mg SL or 5-200 µg/min IV titrate | IV/SL | continuous | AHA 2008 PMID 18391116 — nitrate first-line for cocaine vasospastic ischemia + HTN; benzo + nitrate combination preferred over β-blocker |
| diltiazem | 10-20 mg IV bolus then 5-15 mg/h titrate | IV | titrated | AHA 2008 PMID 18391116 — non-DHP CCB for cocaine vasospasm or rate control; alternative to verapamil |
| phentolamine | 5-15 mg IV q5-15 min | IV | titrated | AHA 2008 PMID 18391116 — pure α-blockade for refractory cocaine HTN; reverses unopposed α-stimulation; preferred over β-blocker monotherapy |
| magnesium sulfate | 2 g IV over 15 min then 1-2 g/h titrate Mg 2-2.5 | IV | continuous if TdP | AHA 2020 ACLS Class IIa for TdP; cocaine + co-ingestion (methadone, antipsychotics) prolong QTc; Mg replacement essential |
| naloxone | 0.4-2 mg IV / IM / IN q2-3 min | IV | titrated to respiratory recovery | AHA 2020; fentanyl-contaminated cocaine increasingly common; naloxone first-line if any opioid co-ingestion suspicion + respiratory depression |
| propofol | 5-50 µg/kg/min | IV | continuous; titrate RASS | PADIS 2018; propofol additive sympatholytic effect helpful in cocaine-related sympathetic surge |
| fentanyl | 25-200 µg/h | IV | continuous | PADIS 2018; analgesia + shivering suppression for TTM |
| metoprolol | AVOID monotherapy in active cocaine intoxication — only after 24-48h cocaine washout AND with concurrent α-blockade or after cocaine fully metabolized | PO | do_not_use_acutely | Lange NEJM 1989 PMID 2522592 + AHA 2008 PMID 18391116 + ACC/AHA 2025 ACS Class III — β-blocker monotherapy in active cocaine intoxication produces unopposed α-stimulation, worsening coronary vasospasm + HTN; only consider after 24-48h washout for chronic GDMT if cocaine cardiomyopathy + HFrEF + sustained abstinence |
Plan: Cocaine-related arrest resuscitation phenotype — benzo + bicarb + AVOID β-blocker monotherapy + standard post-ROSC bundle (AHA 2008 PMID 18391116 + AHA 2020 ACLS PMID 33081530 + ACC/AHA 2025 ACS Class III β-blocker monotherapy in active cocaine intoxication)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiology follow-up at 2-4 weeks: echo for heart pumping strength (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
Guideline: AHA 2008 Cocaine-Associated Chest Pain Scientific Statement + AHA 2020 ACLS / Post-Cardiac-Arrest Care + ACC/AHA 2025 ACS Guideline + Lange NEJM 1989 cocaine + propranolol + AHA 2010 toxicology bicarb + TTM2 + Sandroni 2021