The cocaine- or amphetamine-intoxicated patient can often be identified initially by vital signs. Adrenergic stimulation may produce tachycardia, tachypnea, hypertension, and possibly hyperthermia. The patient's mental status can range from normal to paranoid or severely agitated to coma. Organ-system involvement may be suspected from symptoms such as chest pain, palpitations, dyspnea, headache, or focal neurologic complaints. The patient may be postictal or may present with seizures. Other physical findings may include mydriasis and diaphoresis. In the absence of an adequate history, it may be difficult to distinguish this presentation from other conditions of catecholamine excess, such as withdrawal from alcohol or sedative-hypnotics. Metabolic acidosis may be present following seizures or as a result of vasoconstriction and hypoperfusion. As with all intoxicated patients, occult trauma and hypoglycemia must be excluded.
Concomitant use of alcohol and other drugs frequently alters the clinical presentation. For example, a patient ingesting both opioids and stimulants may present with a decreased level of consciousness and few if any other revealing findings. When the opioid is reversed with naloxone, the stimulant effects are unmasked, sometimes in dramatic fashion.
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