ICU and trauma09 / 13
Cocaine toxicity with a femoral artery stab wound23-year-old man, 75 kg, stab wound to the left thigh with femoral artery injury
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Know this first
- Cocaine: tachycardia, hypertension, hyperthermia, sweating, agitation, seizures.
- Sedation for agitation; no beta-blockers for spasm or hypertension.
- Coronary spasm responds to nitrates, phentolamine or a calcium channel blocker.
- Wide-complex tachycardia: sodium bicarbonate 50–150 mEq.
- Core temperature over 40 °C: rapid cooling, immersion fastest.
The patient
23-year-old man, 75 kg, stab wound to the left thigh with femoral artery injury; bleeding controlled by a paramedic tourniquet.
Agitated and sweating; admits snorting cocaine an hour ago. Pupils dilated.
No regular drugs. Emergency vascular repair.
Vitals: BP 168/104, HR 138, SpO2 98%, RR 24, temperature 38.6 °C; Hb 10.2 g/dL.
The examiner asks
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Consider
What are your concerns?
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- A 23-year-old with a femoral artery stab wound and acute cocaine toxicity, for emergency vascular repair. Patient
- As a trauma patient: xABCDE; the tourniquet controls x, and I note when it went on.
- Sympathomimetic toxidrome: fast, hypertensive, hot, sweating, agitated. Disease
- Cocaine can cause coronary spasm, ischaemia and arrhythmias up to VF.
- Surgery isn't delayed for the drug; its effect usually lasts under 2 hours. Surgery
Prepare
How do you prepare him?
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- Sedate his agitation first: midazolam 1–2 mg IV, titrated. Disease
- No beta-blocker for his pressure or heart rate.
- Nitroglycerin drawn up for ischaemia.
- Massive transfusion activated, two large-bore lines, blood warmer ready. Crisis
- 12-lead ECG for ischaemia and a widened QRS from sodium-channel block. Disease
- Core temperature probe; ice and cooling equipment in the room.
Plan
How do you anaesthetise him?
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- Rapid sequence: propofol and rocuronium 1.2 mg/kg. Airway
- Blunt the intubation surge: fentanyl 1–2 mcg/kg with lidocaine 1–1.5 mg/kg.
- Nothing that adds to his sympathetic drive, so no ketamine. Disease
- Hypertension: deepen, then nitroglycerin 50–100 mcg boluses.
- CK and urine checked for rhabdomyolysis.
- HDU or ICU after; addiction services before discharge. After surgery
Crisis
Five minutes after induction, ST elevation appears in V2–V4; BP 172/100, HR 130. What do you do?
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- Cocaine coronary spasm: tell the surgeon, 100% oxygen. Crisis
- Nitroglycerin infusion 0.5–5 mcg/kg/min to relieve the spasm.
- Persistent: a calcium channel blocker or phentolamine.
- Still no beta-blocker, even for his tachycardia.
- Broad QRS or VT: sodium bicarbonate 50–150 mEq IV.
- Cardiology now; angiography if ST elevation persists after repair. After surgery
Crisis
As he wakes he is thrashing; temperature 40.4 °C, HR 150. What do you do?
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- Life-threatening cocaine hyperthermia: keep him asleep and ventilated. Crisis
- Cool fast: evaporative cooling and ice; immersion is quickest if feasible.
- Sedate, not restrain: restraint without sedation is harmful.
- Cocaine mimics MH, with fever, rigidity and rhabdomyolysis; I review what I gave.
- Potassium, CK and urine for rhabdomyolysis.
- ICU ventilated until his temperature and agitation settle. After surgery
Fatal mistakes
- A beta-blocker for cocaine hypertension or tachycardia.
- Letting his temperature climb uncontrolled.
- Missing ongoing bleeding behind the high pressure.
Checked against: AHA guidelines: special circumstances of resuscitation (2025) · Stoelting 8e · Updated initial trauma management: key changes in ATLS (2026)
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