Charles V. Wetli

Fatal Excited Delirium Following Cocaine Use: Epidemiologic Findings Provide New Evidence for Mechanisms of Cocaine Toxicity

We describe an outbreak of deaths from cocaine-induced excited delirium (EDDs) in Dade County, Florida between 1979 and 1990. From a registry of all cocaine-related deaths in Dade County, Florida, from 1969-1990, 58 EDDs were compared with 125 victims of accidental cocaine overdose without excited delirium. Compared with controls, EDDs were more frequently black, male, and younger. They were less likely to have a low body mass index, and more likely to have died in police custody, to have received medical treatment immediately before death, to have survived for a longer period, to have developed hyperthermia, and to have died in summer months. EDDs had concentrations of cocaine and benzoylecgonine in autopsy blood that were similar to those for controls. The epidemiologic findings are most consistent with the hypothesis that chronic cocaine use disrupts dopaminergic function and, when coupled with recent cocaine use, may precipitate agitation, delirium, aberrant thermoregulation, rhabdomyolysis, and sudden death.

Cocaine-associated agitated delirium and the neuroleptic malignant syndrome

The incidence of this previously rare disorder, cocaine-associated agitated delirium, appears to have increased drastically within the last 18 months. The underlying neurochemical abnormalities have recently been characterized, but most clinicians have had little experience with management of agitated delirium. The basic clinical and pathological features of this disorder are reviewed, and common pitfalls in diagnosis and management that frequently lead to needless but very expensive litigation are discussed.

Criteria for the Interpretation of Cocaine Levels in Human Biological Samples and Their Relation to the Cause of Death

The determination that cocaine is directly responsible for the immediate cause of death should be considered only when there is a reasonably complete understanding of the circumstances or facts surrounding the death. Another, more obvious and immediate cause of death must be absent, or, at least cocaine must be shown to be a significant contributing factor in the chain of medical findings that lead directly to the immediate cause of death. Not all death investigation requires the sequential steps described in this paper, but these steps must be considered early on in the investigation whenever there is scene, investigational, medical or a historical basis to believe that cocaine is directly related to the cause of death. A relatively high profile death when cocaine is known to be involved, or a death involving unusual behavior on the part of the deceased with police involvement are examples where these considerations may well apply. Information needs to be obtained as soon as possible to have the highest chance of successfully documenting the toxicologic basis for the diagnosis. These facts would include, but would not necessarily be limited to, a scene investigation (whenever possible), a careful review of the investigative reports from all involved agencies, the initial core temperature of the body as well as that of the environment at the time of the collapse or death, the past medical history of the individual, and the results of a complete forensic autopsy and toxicologic studies. Knowledge of and an understanding of the current relevant forensic literature on this subject should be available to the reviewer prior to any interpretation of the significance of cocaine upon a specific death.

The Forensic Significance of Conjunctival Petechiae

Conjunctival petechiae were mentioned in 227 (4.5%) of 5,000 consecutive autopsy reports of the Dade County Medical Examiner Department. They were most frequently observed in those who had died natural deaths (particularly due to cardiovascular disease), followed by those who had died from asphyxia, head injury, and central nervous system disorders. The incidence of conjunctival petechiae in victims of homicidal asphyxiation was 78%. These data suggest that conjunctival petechiae most often are the result of hypoxia coupled with an acute increase in cephalic vascular pressure. The latter factor may be the consequence of mechanical vascular obstruction or acute right heart failure

Fatal heroin body packing.

The deaths of 10 heroin body packers are reported and contrasted to those of cocaine body packers. Only one was a woman, and all were traveling to or from Colombia. Drug packets deteriorated in the gastrointestinal tract and caused the deaths of eight victims. Accomplices removed drug packets from two of these smugglers after death occurred. One died of peritonitis stemming from a small-bowel obstruction caused by the drug packets, and one died from the recreational use of heroin (nasally ingested). The heroin recovered was < or = 881 g, and the drug purity of the contraband in three cases was between 65% and 73%. Blood concentrations of morphine were < 1.0 mg/L in four victims; no morphine was detected in the smuggler who died of peritonitis. However, two victims had blood morphine concentrations of 4.4 mg/L and 6.7 mg/L, respectively, and three had morphine concentrations of 35.8, 39.4, and 52.6 mg/L, respectively. Fatal heroin body packing differs from cocaine body packing in that individuals may have extremely high drug levels in their blood and their accomplices appear to be more likely to abandon them in a remote location after attempting to remove the drug packets after death has occurred.

Keraunopathology. An analysis of 45 fatalities.

An analysis of 45 victims of fatal lighting strike revealed the incident occurred most frequently in the early afternoon during midsummer in a field of one form or another. The scene of death, damage to clothing, and alterations of metallic objects on the victim are described. A terminal cardiac rhythm of ventricular fibrilation was recorded in half for whom data were available, and asystole was found in 40%. All but four had cutaneous injuries, and nearly one-third had pathognomonic patterns of erythematous arborization. When examined, tympanic membranes were found to be ruptured in > 80%. This study also revealed that craniocerebral injury and cardiac contusion can be serious direct consequences of lightning strike. A correlative approach to the investigation and autopsy of lightning victims is suggested.

Fungal cerebritis from intravenous drug abuse.

Three intravenous drug abusers (predominantly cocaine) developed a fulminant fungal cerebritis without any other identifiable predisposing factor. Two died and one survived with a severe neurologic deficit. Zygomycetes (nonseptated fungi) were identified in the brain tissue of two victims and Acremonium alabamensis was cultured from the brain tissue of the third. Fulminant fungal cerebritis in intravenous drug abusers (in the absence of any predisposing illness) may represent a unique variant of the acquired immunodeficiency syndrome (AIDS). Future surviving patients should be evaluated for the possibility of a cellular immune deficiency state in order to confirm this impression.

Mortality from Hurricane Andrew

Hurricane Andrew, a category 4 storm, made landfall in South Florida on August 24, 1992, and caused extensive structural and environmental damage. The Dade County Medical Examiner Department investigated 15 deaths directly related to the storm and another 15 natural deaths indirectly related to the storm. The aftermath of the hurricane continued to create circumstances that lead to 32 accidental deaths, five suicides, and four homicides over the next six months. Traffic fatalities due to uncontrolled intersections accounted for one-third of the post-storm accidental deaths. Dyadic deaths (homicide-suicide) doubled in rate for the six months following the storm. The limited number of direct hurricane deaths is attributed to advance storm warnings, its occurrence on a weekend, the storms passage through less populated areas of the county, and the relatively modest amount of accompanying rainfall.

Sudden death and sickle cell trait: medicolegal considerations and implications.

Sickle cell trait, which affects approximately 8% of American blacks, is generally felt to be a benign condition. Exercise-related collapse in persons with sickle cell trait is a rare but serious complication. It occurs most often in military recruits and deconditioned athletes undergoing intense physical training, but can also occur in other situations in which an individual exerts himself beyond his limits of endurance. Local hypoxia causes intravascular sickling, in turn causing vascular occlusion and organ and tissue damage. This can result in rhabdomyolysis, myocardial ischemia, arrhythmias and sudden death. Risk factors include poor physical conditioning, inadequate hydration, excess heat and/or altitude, heat-retaining clothing and febrile illness. Seven cases are presented, and the implications of the diagnosis of sickle trait-associated collapse and sudden death are discussed.

Atypical autoerotic death. Part II

Autoerotic fatalities encompass a wide array of means and mechanisms used to attain sexual gratification. The most commonly encountered autoerotic practice, specifically, autoerotic asphyxia, denotes death resulting from failure of a release mechanism of the apparatus designed to attain cerebral hypoxia for heightened arousal. Historically, the majority of victims of autoerotic death are Caucasian males under the age of 30. While autoerotic death is most often associated with a constrictive cervical ligature tied to either other parts of the victims body or to an inanimate object such as a door, several other methods have been reported. These modalities include ligature around the thorax or abdomen, plastic bags covering the face, electrical current, inhalation of a toxic gas or chemicals, or partial or total submersion, known as aquaerotic asphyxiation. This study highlights 11 cases of atypical autoerotic death, including asphyxia with a plastic bag, electrocution, and inhalation of butane and nitrous oxide (N2O). Whereas the manner of death in the majority of autoerotic death cases is deemed accidental, we present and analyze unique and equivocal cases representing 4 different manners of death: accident, natural, suicide, and homicide. The 11 victims were all Caucasian and between the ages of 17 and 55. Ten decedents were males, 1 female. A comprehensive investigation incorporating a thorough scene analysis, gathering of the victims history, and complete postmortem examination is necessary to elucidate both the cause and manner of death in these atypical cases.