A 26-year-old man presents to the emergency department one hour after intranasal cocaine use. He is severely agitated, diaphoretic, with heart rate 140/min, blood pressure 180/110 mmHg, and temperature 38.9 degrees Celsius. Chest radiograph and troponins are pending. The most appropriate initial pharmacological agent is:

• A IV lorazepam ✓
• B IV propranolol
• C IV haloperidol
• D Sublingual nifedipine

Explanation

Benzodiazepines are first-line in cocaine intoxication: they reduce central sympathomeditated agitation, tachycardia, hypertension, and hyperthermia. Propranolol is avoided because beta-blockade leaves alpha-mediated vasoconstriction unopposed and can worsen coronary vasospasm and hypertension. Haloperidol lowers the seizure threshold and worsens hyperthermia. Nifedipine has no role in acute cocaine toxicity and may cause coronary steal. If benzodiazepines fail to control hypertension, agents such as phentolamine or nitroglycerin are used instead.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

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