Cocaine, Excited Delirium and Sudden Unexpected Death

At 5:45 a.m., fire department personnel responded to a call concerning an unresponsive person outside a fast-food restaurant.


At 5:45 a.m., fire department personnel responded to a call concerning an unresponsive person outside a fast-food restaurant. Upon their arrival, they found a 41-year-old, 350-lb. male acting strangely and “becoming a nuisance.”1 In accordance with standard operating procedures, the fire department requested the assistance of police department personnel. The first patrol car arrived at 5:58 a.m., whereupon the responding engine left the scene.2,3 A video-recording device installed in the responding police car recorded one police officer approaching the individual and saying, “You have to tell me what is going on.”

At this point, the individual cursed repeatedly at the officers and attempted to place one in a headlock. After instructing the individual to stay back, the two officers attempted to restrain him, striking him repeatedly with their batons. Although knocked to the ground by the police, the individual continued to struggle, and resisted verbal orders and physical attempts to place his hands behind his back. With the assistance of four additional officers, the individual was successfully handcuffed. At this point, outside the view of the police camera, he ceased struggling. He was rolled onto his back, and an officer said, “He’s still got a pulse. I don’t see him breathing.”

Paramedics responded to the scene, and the patient was pronounced dead soon after arrival at the regional Level 1 trauma center. While the death was officially ruled a homicide by the county coroner, he noted that the patient had an enlarged heart, and that both phencyclidine (PCP) and cocaine were detected on toxicological tests. No evidence of internal injury was noted.1,2

Effects of Cocaine

According to data from the U.S. Drug Enforcement Administration (DEA), cocaine remains the second most common illicit drug used in the United States.4 Ten percent of people aged 12 years or over have used cocaine. In 2002, the U.S. DEA seized 61,594 kg of cocaine.

Cocaine exerts its effects through several distinct pathways. Centrally, it modulates the effects of brain neurotransmitters (especially dopamine), accounting for the euphoria associated with cocaine use, but also for the rapid development of tolerance and addiction.5 Cocaine causes epinephrine (also known as adrenaline) release from the adrenal glands, and blocks the reuptake of norepinephrine, thereby resulting in a state of increased physical stimulation.6 Finally, cocaine has effects on the electrical conduction systems of the heart similar to those of tricyclic antidepressants. The concurrent use of alcohol and cocaine produces a new compound, cocaethylene, which lasts longer in the body and has even more potent toxic effects.5,7

Excited Delirium

The term excited delirium (also known as Bell’s mania, lethal catatonia, acute exhaustive mania, agitated delirium) was first used in 1849 to describe psychiatric patients who developed continuous agitation and mania in the presence of fever, then suddenly collapsed and died.8 Excited delirium is currently characterized by the acute onset of bizarre or violent behaviors, including aggression, combativeness, hyperactivity, extreme paranoia, hallucinations, superhuman strength or incoherent shouting.9 Hyperthermia is frequently present.9,10

Fatal excited delirium was first described in seven cocaine users between April 1983 and May 1984.9 Since that time, more than 130 cases of fatal, cocaine-associated excited delirium have been reported in the medical and forensic literature.8,9,11–13 In Miami, excited delirium accounted for 10% of male cocaine deaths; 39% of excited delirium deaths occurred when the victim was in police custody.10 In a review of excited delirium deaths during custody, victims were predominantly male (97%), had an average weight of 220 lbs. and a mean body temperature of 104ºF.8 No apparent racial differences have been noted in recent studies.8,11 Although the majority of reported drug-associated fatal excited delirium cases have involved the use of cocaine, other stimulant agents, including LSD, phencyclidine (PCP) and methamphetamine, have been implicated in excited delirium deaths.12,13 In the case presented above, both cocaine and phencyclidine were detected during postmortem toxicological testing.1,2

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