The Death of Andre Thomas Karl E. Williams, MD, MPH Medical Examiner Allegheny County

Incident Background Spent evening with friend at barbeque Gone for period of time Began acting paranoid and agitated in car Loud agitated behavior in neighborhood Multiple 911 calls Subdued by Swissvale police including use of TASER

Delirium Dictionary definition –a more or less temporary disorder of the mental faculties, as in fevers, disturbances of consciousness, or intoxication, characterized by restlessness, excitement, delusions, hallucinations, etc

Autopsy Findings Superficial trauma to head and extremities –Abrasions of hands and wrists secondary to handcuffing –Abrasions and contusions of legs and arms consistent with contact with concrete –Abrasions of chin and cheek No internal trauma, especially of head and neck, that would show an injury that would have contributed to his death

Toxicology Findings Presence of cocaine and cocaine byproducts (metabolites) –Cocaine (blood) ng/ml –Benzoylecgonine (blood) ng/ml Metoprolol (Lopressor) ng/ml Alcohol - 50 mg%

Implications of Toxicology Pattern of cocaine and byproducts is consistent with recent consumption – approximately two to three hours Metoprolol – –Present in therapeutic levels –Affects dopamine levels in the brain –Known in rare cases to cause delirium and hallucinations

Studies on Brain Tissue Dr. Deborah Mash/University of Miami Cocaine is known to have its effect by increasing dopamine levels in specific areas of the brain Dopamine receptors remove the dopamine from the nerve synapses as it is formed In cases of Excited Delirium Syndrome the levels of the receptors are decreased leading to increased dopamine levels at the synapses Increased dopamine leads to psychotic and agitated behaviors –May be genetic factors involved

Review of Cases Coroner/ME – 2000 to 2008 Total of 98 cocaine related cases Eight “delirium” –excited or agitated findings 2000 (1) 2005 (1) 2006(2) 2007 (2) 2008 (2) –Five related to cocaine with brain studies consistent with Excited Delirium Syndrome One “agitated/excited delirium” –Two (including this decedent) with brain studies consistent with acute cocaine intoxication –One a psychiatric inpatient with multiple psychotropic medications

Modes of Intervention Primarily Police – 5 –Handcuffs/”shackles” – 5 –Pepper spray – 2 –Taser – 3 Single officer with “bystanders” – 1 EMS only – 1 Medical attendants in hospital - 1

Report on Brain of Decedent Increase rather than decrease in dopamine transporter sites - consistent with chronic cocaine abuse. Possible effect of metoprolol on dopamine levels in brain Delirium due to cocaine use – not Excited Delirium syndrome

Death Certification Agitated Delirium Due to acute cocaine intoxication 1.Taser cannot be shown medically to have contributed to death 2.No evidence of asphyxial component