Delirium, cocaine

Figure 6.1 Tracking the incidence of cocaine overdose deaths in Dade County, FL. Medicolegal investigations of the deaths were conducted by forensic pathologists. Forensic pathologists evaluated the scene environment and circumstances of death and autopsied the victim in order to determine the cause and manner of death. The circumstances of death and toxicology results were reviewed before classifying a death due to cocaine toxicity with or without preterminal delirium. There was a sharp increase in the incidence of cocaine-related and cocaine overdose cases with the arrival of crack cocaine in Dade County. The incidence of cocaine delirium victims is shown by year, from the first report in 1982.

A post-mortem examination and a rectal temperature of 41°C (106°F) were recorded. He had needle marks typical of intravenous drug abuse and pulmonary and cerebral edema. Abrasions and contusions of the ankles and wrists were evident from his struggling. Lidocaine was not administered to the victim during the resuscitative attempts. The clinical presentation of cocaine delirium... 

Table 6.2 Common Traits Associated with the Fatal Cocaine Delirium Syndrome...

In the epidemiological tracking of agitated delirium victims in Metropolitan Dade County, men with preterminal delirium comprised approximately 10% of the annual number of cocaine overdose deaths. The demographic trends show that the proportion of these cases remains consistent throughout the epidemic of cocaine abuse and tends to track the annual frequency of cocaine-related sudden deaths. This observation suggests that a certain percentage of cocaine addicts may be at risk for cocaine delirium with chronic abuse. 

At present it is not clear whether extreme agitation, delirium, hyperthermia, and rhabdomyolysis are effects of cocaine that occur independently and at random among cocaine users, or whether these features are linked by common toxicologic and pathologic processes.20 Ruttenber and colleagues20 have examined excited delirium deaths in a population-based registry of all cocaine-related deaths in Dade County. This study has led to clear description of the cocaine delirium syndrome, its pattern of occurrence in cocaine users over time, and has identified a number of important risk factors for the syndrome. 

When cocaine is repeatedly administered, DAergic receptor numbers are altered.4041 The likelihood of hyperthermia may be increased with chronic cocaine abuse if the DAergic receptors involved in thermoregulation are undergoing adaptive changes with chronic cocaine exposure. In keeping with this hypothesis, cocaine delirium victims had a different profile of D2 receptor binding... 

Toxicity 1. Excess NE cardiac arrhythmias, generalized ischemia with possible MI and strokes acute renal and hepatic failures 2. Excess DA major psychosis, cocaine delirium 3. Excess 5HT possible serotonin syndrome 4. All of the above convulsion, hyperpyrexia, and death... 

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