In four cases presented from the Philadelphia medical examiner's office, sudden death from cardiac arrhythmia or respiratory arrest occurred after minor blunt head trauma from forcible restraint techniques to control individuals in a state of agitated delirium. In these cases, the head injury was insufficient to be a cause of death. Cardiac sympathetic sensitization due to inhibition of neuronal uptake of norepinephrine and dopamine may lead to fatal cardiac arrhythmia with minor blunt head trauma. Am J Forensic Med Pathol 15:95, 1994. The syndrome was first described in Miami in the mid-1980s. It may involve the use of cocaine, amphetamines, PCP, and alcohol. The individual may have extreme paranoia, great strength, and hyperthermia. Forceful restraint with minor head trauma may result in sudden collapse, respiratory arrest, and death. At least 20 people have died of the syndrome while in police custody in the St. Louis area over the last decade. John Carlton, Post Dispatch D1, Jan. 26, 1997. Drs. Welti and Marsh describe this syndrome as a variant of the highly lethal neuroleptic malignant syndrome seen in individuals taking dopamine antagonists and often associated with muscle rigidity. Am J Emerg Med 14: 425, 1996.
Penetrating injuries in chronic cocaine users may be associated with hypotension and tachycardia, which may be due to cardiogenic shock or hemorrhagic shock. A metabolic acidosis is prominent and pulmonary artery pressure measurements may be helpful. Toxic cardiomyopathic states are treated with volume, nitroglycerin, and avoidance of beta-blockers. Treatment of tachycardias with beta-blockers has resulted in cardiac arrest in trauma patients receiving laparotomies. Anesthesiology 85:933, 1996.
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