Eighteen cases of such deaths witnessed by emergency medical service (EMS) personnel are reported. The 18 cases reported were restrained with the wrists and ankles bound and attached behind the back. This restraint technique was also used for all 196 surviving excited delirium victims encountered during the study period. Unique to these data is a description of the initial cardiopulmonary arrest rhythm in 72 percent of the sudden death cases. Associated with all sudden death cases was struggle by the victim with forced restraint and cessation of struggling with labored or agonal breathing immediately before cardiopulmonary arrest. Also associate was stimulant drug use (78 percent), chronic disease (56 percent), and obesity (56 percent). The primary cardiac arrest rhythm of ventricular tachycardia was found in 1 of 13 victims with confirmed initial cardiac rhythms, with none found in ventricular fibrillation. The findings indicate that unexpected sudden death when excited delirium victims are restrained in the out-of-hospital setting is not infrequent and can be associated with multiple predictable but usually uncontrollable factors. (Published Abstract)