Excited delirium, restraints, and unexpected death: a review of pathogenesis.

Unexpected deaths periodically occur in individuals held in police custody. These decedents usually have had significant physical exertion associated with violent and/or bizarre behavior, have been restrained by the police, and often have drug intoxication. Autopsy material from these cases may not provide a satisfactory explanation for the cause of death, and these deaths are then attributed to the excited delirium syndrome. The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress. This syndrome develops secondary to the toxic effects of high levels of catecholamines on either cardiac myocytes or on the coronary microvasculature. Patients with stress cardiomyopathy have unique ventricular morphology on echocardiograms and left ventricular angiography and have had normal coronary angiograms. People who die under unusual circumstances associated with high catecholamine levels have contraction bands in their myocardium. Consequently, the pathogenesis of the excited delirium syndrome could be evaluated by using echocardiograms in patients brought to the emergency centers, and by more careful assessment of the myocardium and coronary vessels at autopsy. Treatment should focus on prevention through the reduction of stress.