Which drug class is considered first-line to blunt sympathetic stimulation in cocaine toxicity?

• A. Ketamine
• B. Benzodiazepine
• C. Nitroglycerin
• D. Nifedipine

Answer: (B)

Blunting the acute sympathetic surge in cocaine toxicity is best achieved with benzodiazepines. These drugs enhance GABAergic inhibition in the CNS, which reduces central sympathetic outflow and quickly lowers agitation, heart rate, and blood pressure. By decreasing the patient’s adrenergic drive, benzodiazepines also lessen myocardial oxygen demand and help prevent seizures or hyperthermia that can accompany cocaine use. Because of this central calming effect, intravenous benzodiazepines such as midazolam or diazepam are the most appropriate first step to control the sympathetic storm.

Other options don’t address the root issue as effectively. Ketamine can elevate sympathetic tone and worsen hypertension and tachycardia. Nitroglycerin helps with chest pain and vasospasm but doesn’t suppress the underlying sympathetic drive. Nifedipine is less favorable due to potential reflex tachycardia and less reliable control of BP.