Sympathomimetic Toxicity (Cocaine/Amphetamines) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Severity
   Sympathomimetic toxidrome — severity? (Toxidrome (agitation + hyperthermia + tachycardia + hypertension + mydriasis + diaphoresis + hallucinations/psychosis) — cocaine/amphetamine/methamphetamine/MDMA/cathinones (bath salts). Dangers: seizures, rhabdomyolysis → AKI, coronary/cerebral ischemia, ICH, cardiovascular collapse. Differentiate: anticholinergic (dry skin), serotonin syndrome, NMS, thyroid storm, withdrawal, ICH.)
   • Severe (hyperthermia/seizures/chest pain/rhabdo/unstable) → Severe → sedate + cool, avoid beta-blockers
   • Mild–moderate (agitation/hypertension/tachycardia) → Mild–moderate · benzodiazepines
2. [End] Mild–moderate · benzodiazepines
   Mild–moderate: benzodiazepines first-line (control agitation/hypertension/tachycardia, repeat and up-titrate, add an antipsychotic such as olanzapine if needed — watch QTc/cooling); stop the drug; fluids; monitor ECG/temperature/CK; altered mentation/seizure → head CT to exclude ICH. Most settle with sedation.
3. [End] Severe → sedate + cool, avoid beta-blockers
   Severe (hyperthermia/seizures/chest pain/rhabdomyolysis/unstable): high-dose benzodiazepines for agitation/seizures; hyperthermia → aggressive physical cooling (antipyretics do not work — heat comes from muscle activity; for severe cases paralyze + intubate with a non-depolarizing agent); fluids + treat rhabdomyolysis; avoid beta-blockers (unopposed alpha → worse vasoconstriction, especially cocaine), use alpha-blockade (phentolamine)/nitroprusside/nicardipine for refractory hypertension; cocaine wide QRS → bicarbonate; evaluate chest pain as ACS (avoid beta-blockers).

Source guidelines & references

• Sympathomimetic toxicity (StatPearls; EMCrit; CorePendium)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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