This handout is for sympathomimetic toxidrome. Your care team identified this based on: reported / suspected cocaine, amphetamine, methamphetamine, mdma, "bath salts", or prescription stimulant use [acmt agitation guidance].
Other reasons your team may use this plan: severe agitation / psychosis + tachycardia + hypertension + diaphoresis + mydriasis (sympathomimetic toxidrome cluster) [goldfrank tox]; core temperature >38.5°c with agitation/combativeness (excited-delirium / hyperthermic toxidrome) [aha 2024 cocaine statement]; chest pain after cocaine/stimulant use (coronary vasospasm / acs) [aha 2024 cocaine cardiovascular statement].
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 | 2–4 mg IV, repeat q5–10min titrated to calm/non-agitated; no fixed ceiling — escalate to large cumulative doses | IV/IM | q5–10min PRN titrated | ACMT agitation guidance — benzodiazepines are the unifying first-line therapy; reduce central catecholaminergic drive, lower HR/BP/temperature, and abort stimulant-induced seizures |
| diazepam | 5–10 mg IV q5–10min titrated | IV | q5–10min PRN titrated | Rapid-onset alternative; long active metabolites useful for sustained cathinone agitation |
| midazolam | 5–10 mg IM (or 0.1 mg/kg) for the undifferentiated severely agitated patient without IV access | IM/IV | q5–10min PRN titrated | ACMT — fast IM absorption; first-choice when IV access is unsafe in a combative patient |
| ketamine | 4–5 mg/kg IM or 1–2 mg/kg IV for benzodiazepine-refractory extreme agitation | IM/IV | single dose; prepare for airway | Rescue dissociative sedation for refractory excited delirium when rapid control prevents acidosis/hyperthermia death; have airway/RSI ready |
Plan: Sympathomimetic toxidrome — benzodiazepine sedation → active cooling → fluids/rhabdo-AKI → cocaine cardiac/HTN → bicarbonate wide-QRS → severe hyponatremia (AHA 2024; ACMT)
Call 911 or go to the nearest emergency room right away if you have:
Substance-use disorder referral + harm reduction (naloxone co-prescription if opioid co-use), cardiology follow-up for cocaine-associated myocardial injury, nephrology if AKI, psychiatry safety plan if intentional, social work [AHA 2024; ACMT]
Guideline: AHA Cocaine-Associated Cardiovascular Disease Scientific Statement (2024-2025) + ACMT stimulant / acute-agitation guidance + 2024-2025 critical-care toxicology reviews of sympathomimetic poisoning and excited delirium