What is the most appropriate med to administer after cocaine overdose when QRS is widened?

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When cocaine overdose produces a widened QRS, it reflects sodium channel blockade in the heart. The most effective antidote in this situation is intravenous sodium bicarbonate because it does two helpful things: it alkalinizes the blood, which reduces the ability of cocaine to block the sodium channels, and it provides an increased extracellular sodium load to help drive current through those channels. This combination helps restore normal conduction and narrows the QRS, lowering the risk of dangerous arrhythmias.

In practice, give a rapid IV bolus of sodium bicarbonate (often around 1 to 2 mEq/kg) and repeat as needed if the QRS remains widened, aiming for a pH around 7.45–7.55 while closely watching the ECG and blood gases. Diazepam can help with agitation and sympathetic stimulation, but it won’t address the QRS widening. Naloxone isn’t indicated for cocaine toxicity, and activated charcoal is only useful for recent oral ingestion and not for an established conduction abnormality.