Cocaine is an extremely addictive agent which can produce stimulation of the sympathetic nervous system due to the inhibition of catecholamine reuptake at the synaptic junction. Probability of a patient presenting to the operating theatre with acute cocaine intoxication is increasingly likely. The physiological effects of even chronic cocaine abuse on various organ systems have an impact on anesthetic management. A preoperative review of major organ systems is essential. Nitroglycerin has been used in the management of hypertension associated with coronary vasoconstriction. Controversy exists regarding management of ventricular dysrhythmias and asystole. The use of epinephrine to treat asystole is controversial in the presence of a state of excess catecholamines induced by cocaine. General anesthesia may include barbiturates, nitrous oxide, and opioids, but inhalational agents must be used with caution due to their myocardial depressant effects. Regional anesthesia may be a good choice if coagulopathies and hypovolemia are corrected.