Vasopressin in cocaine toxicity

Q: Why vasopressin is preferred over epinephrine in cardio-pulmonary arrest due to cocaine overdose?

Answer: Epinephrine, like cocaine, has alpha-adrenergic effects. Because of this similarity in the cardiovascular effects, administration of epinephrine to a patient who was arrested in a hyperadrenergic state is like "pouring gasoline over the fire." 

 Moreover, cocaine prevents reuptake of exogenously administered epinephrine. Therefore, if epinephrine is used, AHA Guidelines recommend that high-dose epinephrine be avoided and the interval for its administration be increased (q 5-10min). 

 Vasopressin offers considerable advantages over epinephrine in cardiac arrest secondary to cocaine toxicity. The hyperadrenergic state caused by cocaine increases myocardial oxygen demand, and vasopressin increases coronary blood flow, thereby reducing myocardial oxygen availability. Also, cocaine toxicity causes acidosis, and epinephrine loses much of its effectiveness in an acidotic environment, whereas vasopressin demonstrates good efficacy even with severe acidosis.

#hemodynamic

#toxicity

Further reads:

1. Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, Olson KR, Ramoska EA, Lange RA. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016 Jun;54(5):345-64. doi: 10.3109/15563650.2016.1142090. Epub 2016 Feb 26. PMID: 26919414.

2. Richards JR, Le JK. Cocaine Toxicity. 2023 Jun 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28613695.