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The Acutely Agitated Patient: Fatalities and Physiology

Roberts, James R. MD

doi: 10.1097/01.EEM.0000296442.68456.07
InFocus
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Author Credentials and Financial Disclosure: James R. Roberts, MD, is the Chairman of the Department of Emergency Medicine and the Director of the Division of Toxicology at Mercy Health Systems, and a Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, both in Philadelphia. Dr. Roberts has disclosed that he has no significant relationships with or financial interests in any commercial companies that pertain to this educational activity.

Learning Objectives: After reading this article, the physician should be able to:

  1. Describe the clinical issues involved in sudden unexpected death of restrained delirious patients.
  2. Identify the physiological issues involved in sudden unexpected death of restrained delirious patients.
  3. Summarize the factors associated with death while hobble restrained for excited delirium.

Release Date: September 2007

Acutely agitated patients can be quite nasty, extremely rude, and dangerous to the entire medical staff. They rarely endear themselves to even the most understanding clinician. No other specialty is forced to make so many important diagnostic and therapeutic decisions with so little data in totally uncooperative, violent, hostile, or out-of-control individuals. This is a challenge that taxes the physician's patience, ingenuity, negotiating skills, and basic common sense on an almost daily basis.

Whether the agitation is secondary to uncontrolled rage or anger, acute psychosis, alcohol (too much or too little), or drug-induced delirium, the acutely agitated individual usually winds up in the emergency department in short order. Often the medical history is completely lacking, and the patient is so violent and uncooperative that no semblance of a medical history or physical examination, or even vital signs, can be obtained. The prodigious challenge to the EP and nursing staff is to eschew the reflex human nature response of forcibly restraining patients until they cooperate or having them descended upon by a bevy of burly security guards, assigning a 300-pounder to each extremity.

When a patient is a danger to himself and the medical staff and in peril of suffering serious medical consequences from a violently agitated and completely uncontrolled milieu, cooler heads must prevail. The bottom line is that the patient must be controlled in a rapid and humane manner, hopefully prior to the development of rhabdomyolysis, hyperthermia, metabolic acidosis, or cardiac arrest.

Last month I discussed an approach to agitated delirium. The days have long passed when you could simply tie down combative, rude, and dangerous individuals, and wait for them to come to their senses or cooperate with their care. There were problems with LSD and PCP, but these drugs now seem less daunting. Cocaine and methamphetamine have largely changed all that, but a plethora of medical or psychiatric conditions can turn even previously sane people into dangerous, raving lunatics. Such individuals seem ready, willing, and able to bite off your thumb, gouge out your eyes, or spit their HIV/hepatitis-laden drool in your face. And they certainly feel no pain, let alone remorse or embarrassment, for doing so. The sagacious clinician waits only a short time before deciding to intervene and take aggressive and decisive actions to control the situation. Enlightened medical personnel must call the shots. Essentially it's “fire, ready, then aim” under battlefield conditions.

These cases often involve death in a young, previously healthy individual, very charged issues that often make the 6 o'clock news. With racial, social, and police brutality overtones and omnipresent litigation risks, the EP must be squeaky clean on medical intervention and requisite charting issues.

A host of metabolic and respiratory derangements occur in agitated patients who are physically restrained. This month's discussion takes a more focused look of the actual data on these complicated issues.

Unexpected Deaths Related to Restraint for Excited Delirium: A Retrospective Study of the Deaths in Police Custody and in the Community

Pollanen M, et al

Canadian Medical Journal 1998;158(12):1603

The authors reviewed the records of 21 cases of unexpected death during excited delirium while in physical restraints. All deaths were investigated by the coroner of Ontario, Canada (1988 and 1995). Analysis included eyewitness testimony, autopsy findings, clinical history, toxicological data, and other information surrounding the deaths. The restraint method, body positioning, and the use of disabling pepper spray also were included in the analysis, as were cocaine blood levels.

The authors note that early reports of deaths in police custody of acutely psychotic or agitated/hyperactive patients were related to using chokeholds or neckholds. Because stopping the circulation to the brain has obvious detrimental effects, this type of restraint has largely been abandoned. Subsequent investigations focused on physical restraints and the position of the subdued individual with regard to their sudden unexpected deaths. The prone position, especially with a hogtied restraint, is very effective but has come under criticism as causing sudden death. The actual data are lacking or confusing, and circumstantial evidence has been incorrectly assigned as the cause of death, especially by critics of law enforcement and security personnel.

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In the 21 cases, the retrospective diagnosis of excited delirium was made by incorporating a variety of data sources, especially eyewitness accounts. All patients exhibited bizarre or hyperactive behavior, paranoia, shouting, thrashing, or ranting, and were described as possessing excessive strength. The unusual behavior was quite diverse, but often included causing a disturbance in public places and resisting arrest (hence police involvement).

Most of the unexpected deaths occurred in men (20 of 21 cases), with a mean age of 33. All deaths were associated with physical restraint, either in the prone position (18 of 21) or with pressure applied to the neck (3 of 21). About half of the patients restrained in the prone position also had external chest compression applied from one to five people sitting or lying on them. The scenario surrounding the actual death was rather common: the struggling individual suddenly lapsed into tranquility and then arrested.

In about half of the cases (12 of 21), delirium was attributed to a psychiatric disorder. Cocaine was the presumed cause of a drug-induced psychosis in 38 percent (8 of 21). Pepper spray was used in four cases. Autopsy examination revealed hypertensive or atherosclerotic heart disease in four of 21 cases (20%). No patient had an obvious life-threatening physical injury.

Although cocaine and metabolites were found in the blood in a significant number of cases, the mean cocaine blood levels were similar to recreational users and lower than that of people who died only from acute cocaine intoxication.

The pivotal finding was that all patients died unexpectedly while being physically restrained. While cocaine was found, its use was not proven to be the primary cause of death. Pharmacokinetic analysis, however, concluded that there was a recent cocaine binge rather than simple recreational use. Of course, interpreting post-mortem cocaine blood levels can be akin to voodoo science, and is a very poor and likely inaccurate way to relate cause and effect. Levels reported here can be lethal in the absence of restraint, and can certainly cause acute delirium.

The prone position was associated with sudden death, but there were no controls because this method of restraint was used in all cases. Other theoretical contributions included anoxia or restraint-associated asphyxia. The conclusion was that a direct causal relationship between the type of restraint or positioning could not be made.

Comment: This is essentially an observational study that relates unexpected death in police custody to cocaine use, struggling against restraints, and the prone position. It is hardly a cause-and-effect study, and its implications must be evaluated carefully. Simply stated, there are no controls in this or any other reports because some type of restraint or position must invariably occur in the prehospital phase. Potential prehospital sedation aside, physical restraint had to be applied because only with physician interruption can the more desirable chemical restraint trump physical restraint. It's easy to jump on the bandwagon without firm scientific data, but many people do just that when interpreting these highly emotionally and socially charged deaths. (See the excellent discussion in Acad Emerg Med 1999;6[10]:1075.)

Emergency physicians must be aware that people can die while in restraints, and do so quite suddenly and unexpectedly. Once the cardiac arrest occurs, successful resuscitation rates are quite low. The degree of metabolic acidosis can be astronomically impressive. Emotions and testosterone levels run high in restrained individuals, police officers, paramedics, and emergency personnel. It's difficult to divorce oneself from the human nature response of wanting to punish, control, or otherwise dominate such obviously aggressive and hateful individuals. These patients are psychotic, drugged, or in a condition where they certainly will not remember the events. They are totally out of control and cannot be expected to cooperate.

We have all seen cocaine cause an identical uncontrollable scenario, and methamphetamine increasingly does the same. There is not much methamphetamine in my area, and I haven't seen many articles highlighting it, but whether it is methamphetamine, cocaine, PCP, or some yet to be determined designer drug, the issues are similar. It's well known that stimulants alone can kill. While it's impossible to determine the exact relationship between cocaine/methamphetamine and sudden death, such a relationship has to be there.

Factors Associated with Sudden Death of Individuals Requiring Restraint for Excited Delirium

Stratton S, et al

Am J Emerg Med 2001;19:187

These authors highlight the fact that many factors in addition to position, drugs, and type of restraint are associated with sudden death in excited delirium. These include obesity, underlying heart disease, and many unknown others. These authors present a consecutive case series of 18 excited delirium sudden deaths after struggle and during physical restraint. It is a rather interesting article because all cardiopulmonary arrests were witnessed by EMS personnel. In 13 of 18 cases, the initial cardiac rhythm at the time of initial paramedic assessment was known.

These cases were from Los Angeles County EMS and the county coroner's office from 1992 to 1998. Before the data were formally collected, EMS personnel were instructed to document method of restraint, mental status, body position, vital signs, cardiac rhythm, and the use of chokeholds, tasers, or pepper spray when responding to the call. During the six-year period, 18 cases of sudden death witnessed by EMS personnel were analyzed. All of the patients in this series had been hobble restrained. Interestingly, 81 percent of the hobble-restrained patients were initially found in a prone position on arrival of EMS. The data did not allow for a determination of an actual association between the prone position and sudden death while hobble restrained because that was the current accepted method of restraint used in all cases.

There was no preponderance of Hispanic, Caucasian, or African American ethnic groups, and all but one were men. The mean body weight was 91 kg (about 200 pounds). The majority of patients were obtunded or agitated on initial EMS contact.

The scenario was similar in all cases of cardiac arrest. All patients had been struggling, had to be restrained, suddenly ceased their agitation, and developed labored or shallow breathing just prior to the cardiac arrest. Six patients had been given pepper spray, and a taser was used in four cases. Cocaine, amphetamines, and ethanol were present in all but five patients. Cardiomegaly, cardiac hypertrophy, or other cardiac pathology was found in 12 of 18 subjects, and only two of 18 patients lacked stimulant use or heart disease.

Although there was an association with restraints and sudden death, a specific restraint procedure could not be indicted as causal. Because all patients were in the prone position, it was not concluded that this specific position was lethal.

The cardiac rhythm initially was predominantly asystole or a bradycardiac rhythm. Ventricular tachycardia was seen in only one patient and sinus tachycardia in two others. Ventricular fibrillation was not noted. Although some patients had underlying heart disease, it was not concluded that primary cardiac disease was responsible for the death. The contribution of hyperthermia was unknown, although it has been noted that such patients are invariably hyperthermic.

This is also a descriptive but not causal report. The authors merely associate sudden death of restrained, excited, delirious patients with a forceful struggle, prone positioning, stimulant drug abuse, underlying heart disease, and obesity. Importantly, the rapid cessation of a violent struggle was a sign of impending death. The authors conclude that the cause of death in this scenario is multifactorial. Although not emphasized in the report, 196 individuals who were also delirious, prone, and hobbled survived the encounter. Their parameters were not detailed.

Comment: This article highlights risk factors for sudden death during restraint coupled with excited delirium. I was impressed that only two deaths lacked association with stimulant use or heart disease. Like other reports, the data are inconclusive, and do not indict any specific factors. The use and type of restraint are attractive culpable cofactors; however, it should be emphasized that these patients are restrained because they cannot be controlled by other methods. Being restrained puts one at high risk for sudden death, albeit it a relatively low risk given the denominator in the equation. The underlying cause of the delirium, associated clandestine heart disease, hyperthermia, and stimulant drug abuse cloud the picture. Many of these additional variables could be lethal by themselves. Unfortunately, most related factors are unknown, unexpected, and cannot be altered or controlled.

This article also highlights the fact that young individuals who appear relatively healthy can have significant underlying heart disease. What EP, for example, immediately considers a possible underlying cardiomyopathy when faced with a crazed patient who can drag around a gaggle of police and paramedics? Who considers the QTC interval when EKG leads cannot even be placed? Chronic cocaine use, cigarette smoking, and methamphetamine use are well known to lead to cardiomyopathy. The bradycardic nature of the deaths seems to support severe acidosis rather than VT or VF as a primary event. If you have not seen an acute MI and severe coronary artery disease in a 30-year-old who previously seemed healthy as a horse, you have not worked enough shifts.

Re-examination of Custody Restraint Position and Positional Asphyxia

Chan T, et al

Am J Forensic Med Pathol

1998;19(3):201

These authors, one a well published researcher in this area, have previously examined the restraint position and positional asphyxia with regard to excited delirium. Prior unscientific contentions claim that body position restricts chest and abdominal movements to a point that an individual is at risk for potentially fatal hypoventilation and respiratory compromise; hence the term positional asphyxia was born and has persisted in the literature. Although one might intuit that a particular type of restraint will inhibit one's respiratory and cardiac function, this has not been proven to be a lethal scenario for sudden death in custody. This article reviews case reports of custody deaths in hogtied patients, as well as medical literature and physiological studies related to pulmonary and cardiovascular physiology in this specific position. It's well worth reading.

It has been postulated that certain restraint positions prevent adequate chest wall, abdominal, and diaphragmatic movement, impairing normal ventilatory function and breathing. The inability to expand the chest cavity and the adverse effects on pulmonary mechanics and physiology have been posited to cause hypoventilatory respiratory failure. This simply has not been scientifically determined, but it is a common argument, intuitively attractive, and a common litigation issue. Important factors certainly include drug intoxication, catecholamine release, hyperthermia, muscle fatigue, and exhaustion in addition to body positioning. In fact, some investigators have stated that the hobbled or hogtied position would not be expected to be fatal within minutes, even though it is a popular theory advanced by many. Studies on healthy volunteers have offered some data, but drawing conclusions from such studies can be scientifically flawed.

Positional asphyxia has been a theory largely advanced by a 1988 study assessing the effects of postural restraints and oxygen saturation and heart rate following exercise in normal healthy volunteers. (Amer J Forensic Med Pathol 1988;9:16.) Ten healthy individuals were hogtied after exercising on a cross country ski machine to a maximum heart rate of 120 beats per minute. When compared with the sitting position, subjects in the restraint position had prolonged recovery times after exercise in heart rate and peripheral oxygen saturation. Based on these findings, the authors postulated that the deaths occurred in the hogtied position because of adverse physiological respiratory effects of body position. They also postulated that the prone position restricted chest and abdominal movement and decreased tidal volume and placed the patient at risk for hyperventilation, hypercapnia, hypoxia, and asphyxiation. Criticism of this study included the fact that the oxygenation was measured by pulse oximetry, a potentially inaccurate method of determining arterial saturation during exercise. This study is flawed in other ways as well. Although other studies have demonstrated adverse effects of restraints on vital capacity, forced expiratory volume, and maximal ventilation, measurements have not been severe enough to prognosticate death.

In short, these authors conclude that factors other than body positioning appear to be more important determinants of sudden unexpected death in restrained delirious patients. The use of stimulant drugs, underlying heart disease (often drug-induced), physiologic cardiopulmonary stress, hyperactivity, hyperthermia, catecholamine levels, and trauma are thought to be more important factors than mere positioning. Although restraints in general will cause some measurable physiological stress, there is no evidence that body positioning alone, even in the hogtied position, creates enough hypoventilation or respiratory compromise to produce positional asphyxia.

Comment: This article debunks the common myth and misconception that merely hogtying a patient and placing him prone places him in a downward spiral of sudden unexpected death. Such a position may cause some abnormal physiological findings in the cardiovascular and pulmonary system but cannot explain sudden death. Any such argument is quite weak for the true scientist, but it's often lost on the general public.

One study (in a rather obscure journal; try Google) did, however, find significant physiologic derangements of the cardiopulmonary system during restraint, again, in an experimental model only. (Wien Klein Wochenschr 1997;109:359.) Six healthy volunteers who had not exercised were placed prone or kneeling upright in a hobble restraint position for a mere three minutes. Rather dramatic derangements in physiology were found in the prone position, compared with the upright mode: in the prone position mean forced vital capacity and forced expiratory volume decreased by 40 percent, end tidal CO2 increased by 15 percent, heart rate decreased by 21 percent, blood pressure decreased, and cardiac output decreased by 37 percent. This work has not been confirmed, but it sure is dramatic! I find these data almost impossible to believe.

In a better study (Amer J Forensic Med Pathol 2005;26[2]:117), healthy volunteers participated in vigorous exercise with no restraints or with handcuffs behind the back. The lactate levels and heart rates did not differ, and the conclusion was that wrist restraint behind the body (not technically hogtied) did not produce cardiopulmonary compromise in struggling and fatigued individuals. Of course, there have been no studies in drugged, delirious, and hyperthermic individuals who also may have cardiac disease. I will buy the concept that having three people lie on your back while you are violently struggling is a bad idea and compromises your breathing, but the position alone does not kill you.

Although these deaths make the national news, the incidence is extremely small considering the number of agitated patients who undergo restraint on a regular basis. It's an unusual shift when an EP does not see four or five burly police officers or paramedics haul in a raving lunatic with a history of having struggled while being restrained for prolonged periods of time. Most of us never witness sudden cardiac death under these circumstances. When fatalities do occur, death is frequently attributed to maltreatment, usually by law enforcement officials. Medical personnel, especially the EP, need not pile on the person. Once the patient is in the ED, it's probably time for our drugs to do the work of the sweaty restrainers, although this is also only an attractive theory with regard to final outcome. One could easily argue that sedating a hyperventilating patient is a bad idea because it can alter the body's compensation for acidosis. Also, sudden cessation of physical activity might allow acidosis to accelerate because cardiac function might be less. All in all, there are a lot of unanswered questions.

Bottom line: be cognizant of these issues. All of us will likely be faced with such potential disasters. The executive summary with regard to true science is that the limitation of chest wall movement and the production of life-threatening cardiorespiratory dysfunction by any position commonly used by law enforcement officials is simply not enough of an insult to result in sudden death by the consensus of investigators. One should not underestimate the role of underlying unrecognized heart disease and drug toxicity. It is clear that restrained individuals become tachycardic, hyperthermic, and acidotic when struggling against restraints, but why they suddenly stop struggling and quickly die is still a mystery to me. Nonetheless, the prescient and sagacious EP quickly ceases to be a bystander and should restrain such patients chemically, with the expectation that a fatality could be just around the corner.

The challenge to law enforcement officers, EMS personnel, and even the hospital security staff is to balance everyone's safety, often in a no-win scenario where nothing but drugs or physical restraints can control the situation. Unfortunately, only the EP has the right drugs, an attractive yet still theoretical benefit to be sure. Nonetheless, I would conclude that it is best to opt quickly for drugs, but it does require the requisite restraints to get the patient in range of your sedation syringe. How to deal with the recently coded patient has not been studied. I assume standard CPR, perhaps with a boatload of bicarbonate might help, but that is also just theory so far. Future columns will discuss exactly how one can pharmacologically intervene and at least obtain control of the situation, and hopefully alter a potentially disastrous outcome.

Table. FAC

Table. FAC

Reader Feedback: Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Literature references are appreciated. Pertinent responses will be published in a future issue. Please send comments to emn@lww.com. Dr. Roberts requests feedback on this month's column, especially personal experiences with successes, failures, and technique.

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SUMMARY OF THE CIRCUMSTANCES OF SUDDEN DEATH IN RESTRAINED DELIRIOUS PATIENTS

  • ▪ Deaths in delirious restrained patients usually have associated bradycardic rhythms and severe metabolic acidosis, but the exact contribution of these parameters (specifically cause and effect) is uncertain.
  • ▪ Severe exertion and physical activity during attempts to escape or associated violent behavior prior to restraint will cause metabolic acidosis.
  • ▪ Cocaine/amphetamines and other stimulants are invariably associated with sudden death during restraint, and a causative contribution of these cardiotoxic agents cannot be ignored.
  • ▪ A significant number of individuals who die during excited delirium have underlying cardiac disease, unexpected because of lack of history or young age, some possibly due to chronic stimulant abuse (cocaine/methamphetamine).
  • ▪ While the prone and hobble restraint position produces measurable pulmonary dysfunction, this is likely not enough derangement to be fatal unless other components are present (such as stimulants, intoxicants, cardiac disease, hyperthermia, and acidosis).
  • ▪ When possible, it's best to avoid compression of the individual's chest wall while prone.
  • ▪ Most individuals who are delirious and restrained do not experience sudden death, and it is actually rare.
  • ▪ The majority of fatalities are associated with factors that are unknown (heart disease) or cannot be controlled (agitation) or altered (stimulant use) during the restraint process.
  • ▪ The benefit of rapid chemical restraint, while physiologically and intuitively attractive, has not been proven to alter outcome.
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