Cocaine-Induced Psychosis and Sudden Death in Recreational Cocaine Users

TLDR

Fatal cocaine intoxication presenting as an excited delirium has been observed in seven recreational users, and clinicians should recognize it as a potentially lethal condition requiring immediate transport to a medical facility. The study aims to prevent fatal outcomes by continuous monitoring, administering cocaine antagonists, and providing respiratory support. The authors propose continuous monitoring, cocaine antagonist administration, and respiratory support as the intervention strategy. In seven recreational cocaine users, excited delirium manifested as intense paranoia, violent behavior, hyperthermia, and sudden respiratory collapse within minutes to an hour after restraint, resulting in five deaths in police custody and mean blood cocaine concentrations of 0.6 mg/L—about ten times lower than fatal overdoses.

Abstract

Fatal cocaine intoxication presenting as an excited delirium is described in seven recreational cocaine users. Symptoms began with the acute onset of an intense paranoia, followed by bizarre and violent behavior necessitating forcible restraint. The symptoms were frequently accompanied by unexpected strength and hyperthermia. Fatal respiratory collapse occurred suddenly and without warning, generally within a few minutes to an hour after the victim was restrained. Five of the seven died while in police custody. Blood concentration of cocaine averaged 0.6 mg/L, about ten times lower than that seen in fatal cocaine overdoses. Police, rescue personnel, and emergency room physicians should be aware that excited delirium may be the result of a potentially fatal cocaine intoxication; its appearance should prompt immediate transport of the victim to a medical facility. Continuous monitoring, administration of appropriate cocaine antagonists, and respiratory support will hopefully avert a fatal outcome.