A 27-year-old man is brought to the emergency department agitated and diaphoretic with chest discomfort 40 minutes after smoking crack cocaine. Blood pressure is 214/122 mmHg and heart rate is 128 beats per minute. ECG shows sinus tachycardia without ST elevation. What is the best initial pharmacological intervention?
- A Intravenous lorazepam ✓
- B Intravenous propranolol
- C Sublingual nifedipine
- D Intravenous diltiazem
Correct answer: A. Intravenous lorazepam
Explanation
Benzodiazepines are first line in sympathomimetic toxicity because they blunt central sympathetic outflow and often normalize blood pressure alone. Propranolol is contraindicated because blocking beta-mediated vasodilation leaves alpha-mediated vasoconstriction unopposed, potentially worsening hypertension and coronary spasm. Non-dihydropyridine calcium channel blockers are also avoided in stimulant toxicity, and sublingual nifedipine gives erratic, unpredictable falls in blood pressure and is no longer recommended for any emergency.
Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.
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