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A 26-year-old man in status epilepticus is brought into the emergency department by his "friends," who promptly flee the scene. His seizures spontaneously cease, and he is noted to have an altered mental status. IV access is obtained and he is stabilized. A urine toxicology screen is positive for cocaine and his creatine phosphokinase is markedly elevated. He is admitted for cocaine-induced seizures and rhabdomyolysis. He survives the hospitalization and consents to a photograph of his eyes before discharge. Figure 251-1 shows the bilateral subconjunctival hemorrhages that occurred during his seizures. The patient states that he understands the gravity of the situation and will enter a drug rehabilitation program when he leaves the hospital.

FIGURE 251-1

Bilateral subconjunctival hemorrhages after severe cocaine-induced seizures in a young man. This patient also developed rhabdomyolysis and was hospitalized. (Reproduced with permission from Beau Willison, MD.)


Cocaine is a natural alkaloid and is extracted from the Andean shrub known as Erythroxylum coca. Cocaine remains the primary non-alcoholic drug of abuse globally. It is available as a free base in cocaine hydrochloride salt. The water solubility of cocaine lends itself to various routes of administration. Cocaine use is common, and 5% to 6% of users develop dependence within the first year of use. Acutely intoxicated patients have increased heart rates, blood pressures, temperatures, and, initially, respiratory rates; mood changes, involuntary movements; and dilated pupils. Chronic addiction can be treated with a comprehensive program, although only one-third of patients will become and remain abstinent.


Cocaine is also called blow, C, coke, crack, flake, snow, bump, rock, toot, nose candy, and line.


  • Based on the National Comorbidity Survey Replication (NCS-R) using interviews with a nationally representative sample of 9282 English-speaking respondents ages 18 years and older (conducted in 2001 to 2003), the cumulative incidence of cocaine use was 16%.1

  • Similar numbers were reported from the National Survey on Drug Use and Health in 20052:

    • Of Americans ages 12 years and older, 13.8% reported lifetime cocaine use in 2005.2

    • A total of 33.7 million Americans ages 12 years and older reported lifetime use of cocaine, and 7.9 million reported using crack cocaine.2

    • An estimated 2.4 million Americans reported current use of cocaine (682,000 of whom reported using crack).2

    • Of the estimated 860,000 new users of cocaine in 2005, most were age 18 years or older, with the average age of first use being 20 years.2

    • The percentage of youth ages 12 to 17 years reporting lifetime use of cocaine was 2.3%, and among young adults ages 18 to 25 years the rate was 15.1%.2

  • For both male and female cocaine users, the estimated risk for developing cocaine ...

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