The donor had twice visited an emergency department in the preceding 24 hours with complaints of nausea, vomiting, and abdominal pain. He then visited a different emergency department with worsening abdominal pain, nausea, hematemesis, throat pain, and intermittent periods of confusion and agitation and was noted to have ballistic movement of his trunk. When he first arrived, his vital signs were stable; however, within 6 hours he developed tachycardia and hypertension. Because of his agitation and inability to cooperate, he was sedated and intubated before technicians performed a computed tomography (CT) scan of the head that revealed a small subarachnoid hemorrhage (SAH). Over the next 8 hours, he became increasingly agitated (pulling at his restraints, biting the endotracheal tube, and attempting to self-extubate). He was admitted to the intensive care unit for acute cocaine-induced SAH, hypertensive crisis, and rhabdomyolysis (creatinine kinase, 8061 U/L). During the physical examination, his temperature was mildly elevated at 100.5° (oral), his pupils were equal and reactive, his neck was supple, his heart examination result was significant for tachycardia with a regular to irregular rhythm, and his breath sounds were significant for faint crackles and rales that cleared with suctioning. A repeat creatinine kinase level was 3404 U/L; creatinine kinase-MB fraction, 7.9%; and MB index, 0.2. A second troponin I level was 0.44 ng/mL (the initial troponin I level was within normal limits). He was weaned from the ventilator and extubated and continued to have episodes of coughing, retching, and vomiting. He developed generalized tonic-clonic seizures and was reintubated. He remained hypertensive (blood pressure, 199/110 mm Hg) and tachycardic (pulse, 187), and he was diaphoretic and febrile (101.8°). A third troponin I level was 3.61 ng/mL. He continued to have seizure activity, biting his endotracheal tube and tongue, and self-extubated. He soon became apneic and hypotensive and was reintubated. His seizure activity continued and his temperature increased to 106.5°. A neurology consult was obtained at which time he was noted to have absent motor and sensory responses, fixed dilated pupils, and decreased tone and flexor plantar responses. A repeat CT scan was now significant for a large SAH and evidence of herniation. Oculocephalic, gag, and cough reflexes were now absent. An electroencephalogram showed only muscle activity from agonal breaths. A perfusion study was negative for cerebral blood flow, and he was declared brain dead 92 hours after he arrived at the emergency department. Permission was granted for organ donation, and his lungs, kidneys, liver, and iliac vessels were harvested the following day.