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Pediatric Cocaine Abuse Clinical Presentation

  • Author: Anthony J Weekes, MD, RDMS, RDCS; Chief Editor: Caroly Pataki, MD  more...
Updated: Apr 14, 2016


Any patient who presents with symptoms of a cardiac, vascular, pulmonary, neurologic, or psychological problem should provide a drug history. Coordination, response, and judgment may have been influenced by psychoactive drugs in patients involved in vehicular accidents, falls, near-drowning experiences, domestic violence, rapes, and other violent acts or misfortunes. The history should attempt to elicit answers to the following questions:

Identifying the drug or drugs

  • Which drug was used?
  • Was the drug used with any other drugs?
  • How much of the drug was used?
  • The use occurred over what period of time?
  • Was the drug obtained from a usual source?

Prior cocaine use

  • Has the patient used cocaine before?
  • How often?
  • How much?
  • By what route?
  • How long?
  • Has tolerance developed?
  • What withdrawal signs have developed in the past?

Alcohol and nicotine use

  • Does the patient use nicotine or alcohol?
  • What is the extent of either use or dependence?
  • Does the patient smoke or drink before or during cocaine use?

Existing symptoms

  • What symptoms present?
  • Are pain (eg, headache, chest, extremity, abdominal), respiratory problems, anxiety, confusion, seizures, hallucinations, altered mental status, syncope, or dizziness present?
  • Did these symptoms occur with prior use of cocaine?
  • How long after cocaine use did symptoms begin?
  • Are these symptoms due to withdrawal from cocaine?

Comorbid medical conditions

  • Does the patient have other medical conditions (eg, liver disease, pregnancy [lowered serum cholinesterases]) that may lead to greater toxicity from cocaine?

Comorbid disorders may include the following:

Behaviors prompting this evaluation

What behaviors prompted this evaluation? Many psychiatrically disturbed adolescents and young adults brought into emergency departments (EDs) because of emotional outbursts or demonstrative, even dangerous, extremes of behavior may be intoxicated with psychoactive drugs, such as phencyclidine (PCP), cocaine, amphetamines, and lysergic acid diethylamide (LSD). Knowing the duration of action of the various illicit drugs (eg, cocaine's stimulatory effects typically last for 1 h, whereas amphetamines usually cause stimulation for several hours) can help the clinician to determine if behavior displayed is due to a drug or due to an underlying psychiatric illness.

History of present illness from caregiving sources

Elicit reasons for the concern if it is a referral or complaint. What led to the referral and what outcome is expected by the referring person? Determine parents' knowledge of the child's cocaine use patterns and any response and attitude to prior substance abuse treatment.

Interactions with peers and environment

  • Does the patient show any signs of disruptive behaviors or practices present?
  • Does the patient have prosocial hobbies, interests, or recreational activities?

Family history

  • Do any family members have histories of substance use or abuse?
  • Are any family members currently involved in substance use or abuse?
  • What are family members' attitudes about substance abuse?
  • Do any family members have a history of psychiatric disorders?
  • What is the family's socioeconomic status?
  • What is the nature of family functioning (ie, support styles, interaction of family members, demonstrated behaviors and emotions, supervision, disciplinary methods, family stressors)?
  • What family stressors (eg, physical or sexual abuse, neglect, violence, other trauma) are present?

Developmental history

  • Does the patient have developmental delays that may affect current functioning?
  • Does the patient have social skills or communication deficits?
  • What was the patient's highest level of functioning prior to substance use?

Full medical history

School performance and attitudes toward school

Job history

RAFFT questionnaire

The RAFFT questionnaire is a sensitive screening instrument for identifying substance abuse.

  • R (relax): Does the individual drink or take drugs to relax, improve self-image, or fit in?
  • A (alone): Does the individual ever drink or take drugs while alone?
  • F (friends): Do any close friends drink or use drugs?
  • F (family): Does a close family member have a problem with alcohol or drugs?
  • T (trouble): Has the individual ever gotten into trouble from drinking or taking drugs?


Because of the myriad of acute and chronic effects of cocaine use and abuse, the physical examination can be revealing, even in patients who are not acutely intoxicated.

  • Vital signs: The patient may be hyperthermic, tachycardic, and hypertensive; however, a patient who abuses cocaine and is not currently intoxicated may have normal vital signs.
  • Head, ears, eyes, nose, and throat (HEENT): Nasal septal ulcerations or perforations with atrophy of the mucosa suggest IN cocaine abuse. Patients intoxicated with cocaine may have a sympathomimetic syndrome with mydriasis. The patient may have "crack eye," with corneal abrasions and ulcerations from the heat and particulate smoke of crack. Singed nasal hairs and carbonaceous sputum may suggest thermal burns of the respiratory tract.
  • Lungs: Pneumothorax and pneumomediastinum may result from crack use. Careful listening to the lungs and assessing for any subcutaneous air is important. Cocaine use may also lead to noncardiogenic pulmonary edema or to diffuse alveolar hemorrhage. Wheezing may occur from exacerbated asthma or hypersensitivity pneumonitis.
  • Cardiac: Cocaine use is associated with MI, aortic dissection, endocarditis, cardiomyopathy, and bradycardia, as well as virtually all types of tachydysrhythmia. Careful auscultation of the heart, close monitoring, assessment of the pulses, and an ECG are important.
  • GI: Inspect the abdomen for distension, ecchymosis, and bowel sounds. Pain out of proportion to tenderness may suggest bowel ischemia. A rectal examination to detect GI bleeding is indicated.
    • Body packers: Cocaine is carefully wrapped in small well-sealed packets. If body packing is suspected, carefully search the patient's body cavities.
    • Consider diagnostic imaging including CT scan if suspected packets are not detected by abdominal X-ray.
    • Consider administering golytely or whole bowel irrigation.
    • Body stuffers: Cocaine is hastily ingested. Carefully search the patient's body cavities if stuffing is suspected.
  • Skin: Inspect skin for needle punctures (ie, "track marks") or evidence of "skin-popping." Cellulitis, abscesses, and retained needles are complications. Acutely intoxicated patients may be warm and diaphoretic, in contrast to patients who have anticholinergic toxicity, who present with hot and dry skin.
  • Neurologic: Conduct a thorough neurologic examination of any patient with possible cocaine abuse. Mental status, strength, reflexes, sensation, and gait help determine the possibility of cerebral ischemia, infarction, subarachnoid hemorrhage, movement disorders, or seizures.
  • Obstetrical: Assess both fetal and maternal health. Fetal heart and motion monitoring is important. Withhold bimanual examination for third-trimester bleeding until ultrasonography can exclude a placenta previa or abruptio diagnosis.
  • Adulterants used in cocaine such as levamisole may confound and add to the complexity of the side-effect profile.


The NIDA has identified the following risk factors for the development of drug use and abuse[2] :

  • Unstable home environment due to parental substance abuse or mental illness
  • Fractured relationship of parents and adolescent or child
  • Poor level of supervision of the adolescent's activities
  • Peer use of drugs
  • Liberal parental attitude of their own drug use or adolescent's use of drugs
  • Children with conduct disorder or difficult temperaments coupled with ineffective parenting
  • Poor performance in school
  • Apparent ambivalence or approval of drug-using behavior in the school, peer group, or the community
  • Availability of drugs in the community, peer group, or home environment

The consequences of cocaine use, abuse, and dependence include lowered educational achievements, increased trouble with law enforcement (including increased arrests, incarcerations, longer sentences), limited and more limited employment options with worse outcomes, and increased suicidal attempts and completed suicides.[15]

Contributor Information and Disclosures

Anthony J Weekes, MD, RDMS, RDCS Ultrasound Fellowship Director, Associate Director of Emergency Ultrasound, Department of Emergency Medicine, Carolinas Medical Center

Anthony J Weekes, MD, RDMS, RDCS is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Douglas S Lee, MD Attending Physician, Department of Emergency Medicine, Naples Community Hospital

Douglas S Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

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