A 28-year-old man is brought to the emergency department agitated and diaphoretic after using crack cocaine. BP is 210/120 mmHg, pulse 122/min, and he reports chest pain. ECG shows sinus tachycardia with no ST elevation. What is the best initial management?
- A IV benzodiazepine, adding phentolamine or nicardipine if BP remains elevated ✓
- B IV diltiazem infusion for rate and pressure control
- C IV labetalol bolus followed by a labetalol infusion
- D Oral clonidine loading dose
Correct answer: A. IV benzodiazepine, adding phentolamine or nicardipine if BP remains elevated
Explanation
In sympathomimetic toxicity, benzodiazepines are first line because they blunt central sympathetic outflow and often control both agitation and BP. If hypertension persists, a direct vasodilator such as phentolamine or an agent like nicardipine is added. Beta blockers such as labetalol are contraindicated as sole therapy because blocking beta-mediated vasodilation leaves alpha-mediated vasoconstriction unopposed, worsening hypertension and coronary vasospasm. Diltiazem does not address the primary mechanism and clonidine loading is not standard here.
Reference: Katzung's Basic and Clinical Pharmacology, 15th ed.
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