Page 4 - Newsletter March 2020

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is high risk of cardiac arrhythmias during this Forensic medical practitioners are often required to
period” . render a decision as to the cause of death in cases
2
Drugs such as cocaine and amphetamine are that involve patients in police custody with multiple
known predisposing factors for excited delirium. confounding variables such as struggle or alleged
These drugs can increase the physiological effects violence and concomitant illicit substance use.
of a struggle and there by increases the risk of A thorough history, a scene examination, a complete
development of fatal arrhythmias. Cocaine causes autopsy with full range of toxicology and histo-
increased release of Catecholamines together pathology examination is mandatory before coming
with inhibition of norepinephrine reuptake. “Thus, in to any conclusion. The knowledge of this condi-
tion among those who are directly involved in
by these actions, cocaine works on the beta-1
receptors to increase heart rate, force of contrac- arresting suspects is highly recommended as some
tion and conduction velocity, while, at the same of these deaths may be preventable if necessary
time, acting on the alpha receptors in the coronary precautions are taken during arrest, and while keep-
arteries to cause contraction, reducing myocardial ing them in custody.
perfusion.” As a result of this, the myocardial
oxygen demand increases, however myocardial References
perfusion decreases . 1. Samuel E, Williams R. Excited delirium: Consid-
2
Alcohol is a known arrythmogenic agent causing eration of selected medical and psychiatric
variety of atrial and ventricular arrhythmias . Alco- issues. Neuropsychiatric Disease and Treatment
6
holics also known to have increased levels of 2009; 5: 61–66.
norepinephrine. Long QT interval, another affliction 2. DiMaio VJ, DiMaio D. Forensic pathology. 2 ed.
nd
7
to sudden death, is also common in alcoholic . New York: CRC Press; 2001; 511-519.
All these predispositions to arrhythmias can be
3. Young DB, et al., Potassium and catecholamine
aggravated by catecholamines released during a concentrations in the immediate post exercise
violent struggle.
period. Am J Med Sci, 1992; 304(3): 150-153.
In the absence of alcohol and stimulant drugs,
4. Lindinger MI, Potassium regulation during exer-
excited delirium may occur in individuals having cise and recovery in humans: Implications for
endogenous mental disease. These acute psychotic skeletal and cardiac muscle. J Mol Cell Card
episodes are common in individual with schizophre- 1995; 27: 1011-1022.
nia, schizoaffective disorders or delusional disor-
ders. Sudden death can be caused by either the 5. Medbo JI and Sejersted OM, Plasma potassium
physiological effects of catecholamine and hypokale- changes with high intensity exercise. 1990 J
mia following the struggle or a combination of these Physiol; 421: 105-122
effects and the effects of the medications the patient 6. Singer K and Lundberg WB, Ventricular arrhyth-

is or was on . mias associated with the ingestion of alcohol.
2
Excited delirium is a unique medical issue charac- Ann Intern Med 1972; 77: 247-248.
terized by the acute onset of agitation, aggression, 7. Bernardi M, et al., Q-T interval prolongation in
distress, and possibly sudden death. Victims of cirrhosis: Prevalence, relationship with severity,
excited delirium usually die from cardiopulmonary and etiology of the disease and possible patho-
arrest, although the exact cause of such arrest is genetic factors. Hepatology 1998; 27(1): 28-34.
likely to be multifactorial.

Newsletter; Galle Medical Association, March 2020; Volume 20: Issue 1