What is the role of epinephrine and vasopressin in the treatment of cocaine toxicity?

Updated: Dec 31, 2020
  • Author: Lynn Barkley Burnett, MD, EdD, JD; Chief Editor: Sage W Wiener, MD  more...
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Vasopressin offers considerable theoretical advantage over epinephrine in cardiac arrest due to cocaine toxicity. [48, 49] The hyperadrenergic state caused by cocaine increases myocardial oxygen demand. Epinephrine has the same effect. Vasopressin, on the other hand, increases coronary blood flow and myocardial oxygen availability. [50] Cocaine toxicity frequently causes acidosis: epinephrine loses much of its effectiveness in an acidotic milieu [50] , whereas vasopressin demonstrates vasoconstricting efficacy even with severe acidosis. [51]

Epinephrine has been the drug of choice for the treatment of cardiac arrest, primarily for its alpha-adrenergic effects. However, epinephrine and cocaine have many similar cardiovascular effects. Furthermore, cocaine prevents the reuptake of exogenously administered epinephrine. Therefore, if epinephrine is used, the AHA Textbook of Advanced Cardiac Life Support for the Experienced Provider recommends that high-dose epinephrine be avoided and that the interval for its administration be increased (q5-10 min).

If ventricular fibrillation or ventricular tachycardia is recurrent or refractory and epinephrine or excessive levels of endogenous catecholamines are the suspected cause, consider withholding further doses of epinephrine. Because of similarity in cardiovascular effects caused by cocaine and epinephrine, administration of epinephrine to a patient who arrests in a hyperadrenergic state has been likened to "pouring gasoline on a fire." [49]

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