Cocaine-induced agitated delirium, forceful struggle, and minor head injury. A further definition of sudden death during restraint.

Four cases from the Philadelphia Medical Examiner's Office are presented and the literature is reviewed to define further the syndrome of sudden death occurring during cocaine-induced agitated delirium and struggle during restraint in individuals who also sustain minor head injury. The mechanism of death involves a terminal arrhythmia, most likely due to sympathetic sensitization of the myocardium by cocaine and the stress of struggle sometimes juxtaposed upon the stratum of minimal natural disease. In the cases described, the head injury in itself was insufficient to be a cause of death. Recognition of the role of the pharmacologic effect of cocaine and the lethal effects of its use in this setting is crucial.