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68. Alternative agents (eg, calcium channel blockers, vasodilators)
are generally preferred for management of cardiac ischemia in
patients experiencing stimulant intoxication. However, if beta
blockers are used in patients with stimulant intoxication, clinicians
should consider using a medication with concomitant alpha-1
antagonism (eg, carvedilol, labetalol). If an unopposed beta blocker
was used in a patient who is or was recently stimulant intoxicated,
clinicians should also consider providing a coronary vasodilator (eg,
nitroglycerin, calcium channel blocker). For complex cases, consult
with cardiology and/or toxicology (L-C).
69. While treating underlying stimulant intoxication in patients
experiencing chest pain, clinicians should concomitantly evaluate for
ACS and other causes of acute chest pain in stimulant intoxication (eg,
pulmonary, musculoskeletal [MSK]). Chest pain that does not fully
resolve as signs and symptoms of stimulant intoxication improve should
be evaluated and treated following current standards of care (M-S).
QRS Widening
70. Cocaine has local anesthetic-like effects at sodium channels and
can cause QRS widening with impairment in cardiac contractility
during severe cocaine intoxication. If these issues are identified, in
addition to treating intoxication, clinicians should administer sodium
bicarbonate to improve the conduction block and contractility; this
will also improve metabolic acidosis if present (H-S).
Seizure
71. When a patient presents to the emergency department (ED) with
seizures following stimulant use, full neurological workup is not
necessary if the seizures are well explained by substance use or
withdrawal (CC-C).
a. When the etiolog y of the seizures is not well explained by stimulant use, the
workup and management of seizures should proceed according to usual best
practices (CC-S).
72. For stimulant intoxication-related seizures or concomitant
alcohol- or sedative-related seizures, clinicians should treat with
benzodiazepines (H-S).
a. If seizures are refractory to benzodiazepines, clinicians can consider treating
with either phenobarbital or propofol (H-S).
Follow-up
73. Clinicians should screen patients for StUD and engage them in brief
interventions using motivational interviewing (MI) or motivational
enhancement therapy (MET) to facilitate referral for assessment for
StUD, if indicated (VL-C).
