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Sudden cardiac death in excited delirium, and how to prevent it

  • Tina Čakš Golec1,*,
  • Rajko Kavalar1
  • Igor Goričan2
  • Matej Strnad2,3,4

1Department of Pathology, University Medical Centre Maribor, 2000 Maribor, Slovenia

2Emergency Department, University Medical Center Maribor, 2000 Maribor, Slovenia

3Center for Emergency Medicine, Prehospital Unit, Community Healthcare Center, 2000 Maribor, Slovenia

4Department of Emergency Medicine, Medical Faculty, University of Maribor, 2000 Maribor, Slovenia

DOI: 10.22514/sv.2021.222 Vol.19,Issue 1,January 2023 pp.160-165

Submitted: 27 June 2021 Accepted: 06 August 2021

Published: 08 January 2023

*Corresponding Author(s): Tina Čakš Golec E-mail:


The purpose of this study was to review data on restraint related deaths in persons in a state of excited delirium (ExDS) and to propose guidelines for treatment. We analysed three unexpected deaths in persons in a state of ExDS shortly after police restraint. Death which occurs during a police intervention, using physical restraints, may be related to placing the individual in a prone position, the use of neck holds, expert grips, and handcuffs or pepper spray. ExDS results in an altered mental state with agitation, aggression, paranoia, and panic attacks, and is a life-threatening condition. Therefore, before police intervention is initiated, a medical emergency team should be present. In patients with ExDS, physical restraints used by the police should be brief, effective, and include rapid tranquilization (sedation) using benzodiazepines, and antipsychotics.


Cocaine; Dopamine receptors; Delirium; Hyperthermia; Resuscitation

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Tina Čakš Golec,Rajko Kavalar,Igor Goričan,Matej Strnad. Sudden cardiac death in excited delirium, and how to prevent it. Signa Vitae. 2023. 19(1);160-165.


[1] Vilke GM, DeBard ML, Chan TC, Ho JD, Dawes DM, Hall C, et al. Excited Delirium Syndrome (ExDS): Defining Based on a Review of the Literature. The Journal of Emergency Medicine. 2012; 43: 897–905.

[2] Gill JR. The Medicolegal Evaluation of Excited Delirium. Forensic Pathology Reviews. 2008; 325: 91–111.

[3] Ashcroft J, Daniels DJ, Hart SV. The effectiveness and safety of pepper spray. National Institute for Justice: Research for Practice. 2003; 1–15.

[4] Granfield J, Onnen J, Petty CS. Pepper spray and in-custody deaths. Executive Brief: Science and Technology. International Association of Chiefs of Police and National Institute of Justice. 1994.

[5] Kaminski RJ, Edwards SM, Johnson JW. The Deterrent Effects of Oleoresin Capsicum on Assaults Against Police: Testing the Velcro-Effect Hypothesis. Police Quarterly. 1998; 1: 1–20.

[6] Arora N. Cardiac Arrest in a Young Patient Triggered due to Pepper Spray: A Case Report. Austin - Critical Care Journal. 2019; 6: 1026.

[7] Mendelson JE, Tolliver BK, Delucchi KL, Baggott MJ, Flower K, Harris CW, et al. Capsaicin, an active ingredient in pepper sprays, increases the lethality of cocaine. Forensic Toxicology. 2009; 28: 33–37.

[8] Chung YC, Baek JY, Kim SR, Ko HW, Bok E, Shin W, et al. Capsaicin prevents degeneration of dopamine neurons by inhibiting glial activation and oxidative stress in the MPTP model of Parkinson’s disease. Experimental & Molecular Medicine. 2017; 49: e298.

[9] O’Halloran RL, Frank JG. Asphyxial Death during Prone Restraint Revisited. The American Journal of Forensic Medicine and Pathology. 2000; 21: 39–52.

[10] Steffee CH, Lantz PE, Flannagan LM, Thompson RL, Jason DR. Oleoresin Capsicum (Pepper) Spray and “in-Custody Deaths”. The American Journal of Forensic Medicine and Pathology. 1995; 16: 185–192.

[11] Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. Canadian Medical Association Journal. 1998; 158: 1603–1607.

[12] Yeung MF, Tang WYM. Clinicopathological effects of pepper (oleoresin capsicum) spray. Hong Kong Medical Journal. 2015; 21: 542–552.

[13] Venton BJ, Seipel AT, Phillips PEM, Wetsel WC, Gitler D, Greengard P, et al. Cocaine increases dopamine release by mobilization of a synapsin-dependent reserve pool. The Journal of Neuroscience. 2006; 26: 3206–3209.

[14] Li M, Martinelli AN, Oliver WD, Wilkerson RG. Evaluation of Ketamine for Excited Delirium Syndrome in the Adult Emergency Department. The Journal of Emergency Medicine. 2020; 58:100–105.

[15] Van Hout MC. An Internet study of users experiences of the synthetic cathinone 4-methylethylcathinone (4-MEC). Journal of Psychoactive Drugs. 2014; 46: 273–286.

[16] Final report on the safety assessment of capsicum annuum extract, capsicum annuum fruit extract, capsicum annuum resin, capsicum annuum fruit powder, capsicum frutescens fruit, capsicum frutescens fruit extract, capsicum frutescens resin, and capsaicin. International Journal of Toxicology. 2007; 26: 3–106.

[17] Smith J, Greaves I. The Use of Chemical Incapacitant Sprays: a Review. The Journal of Trauma: Injury, Infection, and Critical Care. 2002; 52: 595–600.

[18] Marinelli S, Pascucci T, Bernardi G, Puglisi-Allegra S, Mercuri NB. Activation of TRPV1 in the VTA excites dopaminergic neurons and increases chemical- and noxious-induced dopamine release in the nucleus accumbens. Neuropsychopharmacology. 2005; 30: 864–870.

[19] Plush T, Shakespeare W, Jacobs D, Ladi L, Sethi S, Gasperino J. Cocaine-Induced Agitated Delirium. Journal of Intensive Care Medicine. 2015; 30: 49–57.

[20] Hollander JE, Hoffman RS. Cocaine-induced myocardial infarction: an analysis and review of the literature. The Journal of Emergency Medicine. 1992; 10: 169–177.

[21] Neve KA. Dopamine Receptors. Encyclopedia of Biological Chemistry. 2004; 336: 817–822.

[22] Ritz MC, Lamb RJ, Goldberg SR, Kuhar MJ. Cocaine receptors on dopamine transporters are related to self-administration of cocaine. Science. 1987; 237: 1219–1223.

[23] Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis—an overview for clinicians. Critical Care. 2005; 9: 158–169.

[24] Nzerue CM, Hewan-Lowe K, Riley LJ. Cocaine and the kidney: a synthesis of pathophysiologic and clinical perspectives. American Journal of Kidney Diseases. 2000; 35: 783–795.

[25] Valente MJ, Henrique R, Vilas-Boas V, Silva R, Bastos MDL, Carvalho F, et al. Cocaine-induced kidney toxicity: an in vitro study using primary cultured human proximal tubular epithelial cells. Archives of Toxicology. 2012; 86: 249–261.

[26] Ghuran A, Nolan J. Recreational drug misuse: issues for the cardiologist. Heart. 2000; 83: 627–633.

[27] Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Academic Emergency Medicine. 1999; 6: 239–243.

[28] Chan TC, Neuman T, Vilke GM, Clausen J, Clark RF. Metabolic acidosis in restraint-associated cardiac arrest. Academic Emergency Medicine. 1999; 6: 1075–1077.

[29] Roeggla M, Wagner A, Muellner M, Bur A, Roeggla H, Hirschl MM, et al. Cardiorespiratory consequences to hobble restraint. Wiener Klinische Wochenschrift. 1997; 109: 359–361.

[30] Strömmer EMF, Leith W, Zeegers MP, Freeman MD. The role of restraint in fatal excited delirium: a research synthesis and pooled analysis. Forensic Science, Medicine and Pathology. 2020; 16: 680–692.

[31] Gillings M, Grundlingh J, Aw-Yong M. Guidelines for the Management of Excited Delirium/Acute Behavioural Disturbance (ABD). The Royal College of Emergency Medicine. 2016. Available at: Standards_Guidance/RCEM_Guidance/RCEM/Quality-Policy/Clinical_Standards_Guidance/RCEM_Guidance.aspx?hkey=862bd964-0363-4f7f-bdab-89e4a68c9de4 (Accessed: 1 October 2021).

[32] Plush T, Shakespeare W, Jacobs D, Ladi L, Sethi S, Gasperino J. Cocaine-induced agitated delirium: a case report and review. Journal of Intensive Care Medicine. 2015; 30: 49–57.

[33] Vilke GM, Bozeman WP, Dawes DM, Demers G, Wilson MP. Excited delirium syndrome (ExDS): treatment options and considerations. Journal of Forensic and Legal Medicine. 2012; 19: 117–121.

[34] Witkin JM, Gasior M, Heifets B, Tortella FC. Anticonvulsant efficacy of N-methyl-D-aspartate antagonists against convulsions induced by cocaine. The Journal of Pharmacology and Experimental Therapeutics. 1999; 289: 703–711.

[35] Brackett RL, Pouw B, Blyden JF, Nour M, Matsumoto RR. Prevention of cocaine-induced convulsions and lethality in mice: effectiveness of targeting different sites on the NMDA receptor complex. Neuropharma-cology. 2000; 39: 407–418.

[36] Ho JD, Smith SW, Nystrom PC, Dawes DM, Orozco BS, Cole JB, et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehospital Emergency Care. 2013; 17: 274–279.

[37] Scaggs TR, Glass DM, Hutchcraft MG, Weir WB. Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System. Prehospital and Disaster Medicine. 2016; 31: 563–569.

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