For cocaine-associated tachycardia, which treatment is recommended?

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Multiple Choice

For cocaine-associated tachycardia, which treatment is recommended?

Cocaine can cause tachycardia not only from sympathetic stimulation but also from direct sodium-channel blockade in the heart, which can produce a wide QRS and dangerous arrhythmias. The treatment that directly counteracts this sodium-channel effect is giving intravenous sodium bicarbonate. Alkalinizing the blood shifts cocaine to a more ionized form, reducing its ability to block sodium channels, and the higher extracellular sodium helps overcome the blockade, improving conduction and narrowing the QRS. Dosing is typically 1 mEq/kg IV bolus, repeated as needed with ECG and pH monitoring. While benzodiazepines can help with agitation and sympathetic drive, they don’t address the conduction abnormality; epinephrine would worsen tachycardia and vasospasm, and flumazenil isn’t indicated.

Cocaine can cause tachycardia not only from sympathetic stimulation but also from direct sodium-channel blockade in the heart, which can produce a wide QRS and dangerous arrhythmias. The treatment that directly counteracts this sodium-channel effect is giving intravenous sodium bicarbonate. Alkalinizing the blood shifts cocaine to a more ionized form, reducing its ability to block sodium channels, and the higher extracellular sodium helps overcome the blockade, improving conduction and narrowing the QRS. Dosing is typically 1 mEq/kg IV bolus, repeated as needed with ECG and pH monitoring. While benzodiazepines can help with agitation and sympathetic drive, they don’t address the conduction abnormality; epinephrine would worsen tachycardia and vasospasm, and flumazenil isn’t indicated.

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