Clinical presentation

Cocaine’s onset of action depends on the route of administration:

  • intravenous injection or inhalation (smoking)—30 seconds to 2 minutes
  • snorting or oral—20 to 30 minutes.

Effects of cocaine poisoning typically present as a sympathomimetic toxidrome, including:

  • hyperthermia (temperature more than 39ºC or rapidly rising); if severe, can cause multiorgan failure
  • central nervous system effects
    • excitation—anxiety, euphoria, agitation
    • acute behavioural disturbance, aggression
    • thrombotic or haemorrhagic strokes—usually within 3 hours after exposure
    • headache (common)
    • seizures—most occur as the only manifestation of toxicity and usually within 90 minutes after exposure
    • movement disorders—dystonia, choreoathetosis
  • cardiovascular effects
    • chest pain (common)—usually within 3 hours, but can be up to 24 hours after exposure
    • acute coronary syndrome, myocardial ischaemia or infarction with atypical chest pain, raised serum troponin concentration
    • cardiomyopathy and heart failure—mainly with chronic use, but can occur after acute exposure
    • QRS widening and tachyarrhythmias (sinus tachycardia, atrial fibrillation, supraventricular and ventricular tachycardia
    • QT-interval prolongation and torsades de pointes (rare)
    • aortic dissection (rare)
    • thrombotic and ischaemic events in any vascular bed (eg mesenteric or limb ischaemia)
  • other effects
    • respiratory barotrauma (eg pneumothorax) due to Valsalva manoeuvre during smoking
    • rhabdomyolysis and acute kidney injury
    • effects secondary to adulterants, such as other local anaesthetics (neurotoxicity) or levamisole (agranulocytosis, vasculitis).