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Forensic Science, Medicine and Pathology
Published in: Forensic Science, Medicine and Pathology 4/2020

Open Access 01-12-2020 | Review

The role of restraint in fatal excited delirium: a research synthesis and pooled analysis

Authors: Ellen M. F. Strömmer, Wendy Leith, Maurice P. Zeegers, Michael D. Freeman

Published in: Forensic Science, Medicine and Pathology | Issue 4/2020

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Abstract

The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.
Literature
1.
Baldwin S, Hall C, Bennell C, Blaskovits B, Lawrence C. Distinguishing features of excited delirium syndrome in non-fatal use of force encounters. J Forensic Legal Med. 2016;41:21–7.
2.
Hall C, Votova K, Heyd C, Walker M, Macdonald S, Eramian D, et al. Restraint in police use of force events: examining sudden in custody death for prone and not-prone positions. J Forensic Legal Med. 2015;31:29–35.
3.
Hall CA, Kader AS, McHale AMD, Stewart L, Fick GH, Vilke GM. Frequency of signs of excited delirium syndrome in subjects undergoing police use of force: descriptive evaluation of a prospective, consecutive cohort. J Forensic Legal Med. 2013;20:102–7.
4.
Mash DC, Duque L, Pablo J, Qin Y, Adi N, Hearn WL, et al. Brain biomarkers for identifying excited delirium as a cause of sudden death. Forensic Sci Int. 2009;190:e13–9.PubMed
5.
Byard RW. Ongoing issues with the diagnosis of excited delirium. Forensic Sci Med Pathol. 2017;14:149–51.PubMed
6.
7.
Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. CMAJ. 1998;158:1603–7.PubMedPubMedCentral
8.
Wetli CV, Fishbain D. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci. 1985;30:873–80.PubMed
9.
Di Maio TG, Di Maio VJ. Excited delirium syndrome cause of death and prevention. Boca Raton: CRC Press, Taylor & Francis; 2006.
10.
Gordon C, Schmelzer M. Care of the patient in excited delirium. J Emerg Nurs. 2013;39:190–6.PubMed
11.
Karch SB, Stephens BG. Drug abusers who die during arrest or in custody. J R Soc Med. 1999;92:12–5.
12.
Otahbachi M, Cevik C, Bagdure S, Nugent K. Excited delirium, restraints, and unexpected death: a review of pathogenesis. Am J Forensic Med Pathol. 2010;31:107–12.PubMed
13.
Byard RW. The relationship between positional asphyxia and increasing body mass index. Legal Med. 2020;43:101678.PubMed
14.
Stratton S, Rogers C, Brickett K, Grunzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med. 2001;19:187–91.PubMed
15.
Southall PE, Grant JR, Fowler DR, Scott SR. Police custody deaths in Maryland, USA: an examination of 45 cases. J Forensic Legal Med. 2008;15:227–30.
16.
17.
Ranson D. Excited delirium syndrome: a political diagnosis? J Law Med. 2012;19:667–72.PubMed
18.
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, et al. Excited delirium syndrome (ExDS): defining based on a review of the literature. J Emerg Med. 2012;43:897–905.PubMed
19.
Imam SF, Patel H, Mahmoud M, Prakash NA, King MS, Fremont RD. Bath salts intoxication: a case series. J Emerg Med. 2013;45:361–5.PubMed
20.
Storey M. Explaining the unexplainable: excited delirium syndrome and its impact on the objective reasonableness standard for allegations of excessive force. St Louis Univ Law J. 2012;56:633–63.
21.
Gonin P, Beysard N, Yersin B, Carron P. Excited delirium: a systematic review. Acad Emerg Med. 2018;25:552–65.PubMed
22.
Moher D, Liberati A, Tetzlaff J, Altman D, Group TP. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ Open. 2009;339:b2535.
23.
Price T, O’Neill RM. EMS, crime scene responsibility. StatPearls 2019.
24.
Aberegg S, Erickson B, Cowan M. A 26-year-old man with substance abuse, agitation, and pneumomediastinum. J Lung Pulm Respir Res. 2014;1:1–3.
25.
Alciati A, Scaramelli B, Fusi A, Butteri E, Cattaneo ML, Mellado C. Three cases of delirium after “ecstasy” ingestion. J Psychoactive Drugs. 1999;31:167–70.PubMed
26.
Atherton D, Dye D, Robinson CA, Beck R. n-Ethyl pentylone-related deaths in Alabama. J Forensic Sci. 2019;64:304–8.PubMed
27.
Benzer TI, Nejad SH, Flood JG. Case 40-2013: a 36-year-old man with agitation and paranoia. N Engl J Med. 2013;369:2536–45.PubMed
28.
Blaho K, Winbery S, Park L, Logan B, Karch SB, Barker LA. Cocaine metabolism in hyperthermic patients with excited delirium. J Clin Forensic Med. 2000;7:71–6.PubMed
29.
Bozeman WP, Ali K, Winslow JE. Long QT syndrome unmasked in an adult subject presenting with excited delirium. J Emerg Med. 2013;44:e207–10.PubMed
30.
Bunai Y, Akaza K, Jiang WX, Nagai A. Fatal hyperthermia associated with excited delirium during an arrest. Legal Med. 2008;10:306–9.PubMed
31.
Burnett AM, Watters BJ, Barringer KW, Griffith KR, Frascone RJ. Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehospital Emerg Care. 2012;16:412–4.
32.
Byard R, Cox M, Stockham P. Blunt craniofacial trauma as a manifestation of excited delirium caused by new psychoactive substances. J Forensic Sci. 2016;61:1546–8.PubMed
33.
Corstens D. Excited delirium syndrome after withdrawal from 10 days long recreationally used GHB. J Forensic Legal Med. 2018;54:74–5.
34.
35.
Debelmas A, Benchetrit D, Galanaud D, Khonsari RH. Case 251: nontraumatic drug-associated rhabdomyolysis of head and neck muscles. Radiology. 2018;286:1088–92.PubMed
36.
Desharnais B, Dazé Y, Huppertz LM, Mireault P, Skinner CD. A case of fatal idiosyncratic reaction to the designer drug 3,4-methylenedioxypyrovalerone (MDPV) and review of the literature. Forensic Sci Med Pathol. 2017;13:350–4.PubMed
37.
Downes MA, Berling IL, Mostafa A, Grice J, Roberts MS, Isbister GK. Acute behavioural disturbance associated with phenibut purchased via an internet supplier. Clin Toxicol. 2015;53:636–8.
38.
Dyer JE, Roth B, Hyma BA. Gamma-hydroxybutyrate withdrawal syndrome. Ann Emerg Med. 2001;37:147–53.PubMed
39.
Feeney C, Vu J, Ani C. Acute agitated delirious state associated with taser exposure. J Natl Med Assoc. 2010;102:1254–7.PubMed
40.
Fishbain D, Wetli C. Cocaine intoxication, delirium, and death in a body packer. Ann Emerg Med. 1981;10:531–2.PubMed
41.
Ho JD, Smith SW, Nystrom PC, Dawes DM, Orozco BS, Cole JB, et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehospital Emerg Care. 2012;17:274–9.
42.
Jovel A, Felthous A, Bhattacharyya A. Delirium due to intoxication from the novel synthetic tryptamine 5-meo-dalt. J Forensic Sci. 2014;59:844–6.PubMed
43.
Kasick DP, McKnight CA, Klisovic E. “Bath salt” ingestion leading to severe intoxication delirium: two cases and a brief review of the emergence of mephedrone use. Am J Drug Alcohol Abuse. 2012;38:176–80.PubMed
44.
Kennedy DB, Savard DM. Delayed in-custody death involving excited delirium. J Correct Heal Care. 2017;24:43–51.
45.
Kesha K, Boggs CL, Ripple MG, Allan CH, Levine B, Jufer-Phipps R, et al. Methylenedioxypyrovalerone (“bath salts”) related death: case report and review of the literature. J Forensic Sci. 2013;58:1654–9.PubMed
46.
Kiely E, Lee CJ, Marinetti L. A fatality from an oral ingestion of methamphetamine. J Anal Toxicol. 2009;33:557–60.PubMed
47.
Kodikara S, Cunningham K, Pollanen MS. “Excited delirium syndrome” : Is it a cause of death? Legal Med. 2012;14:252–4.
48.
Kowalski JM, Kopec KT, Lavelle J, Osterhoudt K. A novel agent for management of agitated delirium. Pediatr Emerg Care. 2017;33:e58–62.PubMed
49.
Kristofic JJ, Chmiel JD, Jackson GF, Vorce SP, Holler JM, Robinson SL, et al. Detection of 25C-NBOMe in three related cases. J Anal Toxicol. 2016;40:466–72.PubMed
50.
Kunz SN, Þórðardóttir S, Rúnarsdóttir R. Restraint-related asphyxia on the basis of a drug-induced excited delirium. Forensic Sci Int. 2018;288:e5–9.PubMed
51.
Labay LM, Caruso JL, Gilson TP, Phipps RJ, Knight LD, Lemos NP, et al. Synthetic cannabinoid drug use as a cause or contributory cause of death. Forensic Sci Int. 2016;260:31–9.PubMed
52.
Lucena J, Blanco M, Jurado C, Rico A, Salguero M, Vazquez R, et al. Cocaine-related sudden death: a prospective investigation in south-West Spain. Eur Heart J. 2010;31:318–29.PubMed
53.
Lusthof KJ, Oosting R, Maes A, Verschraagen M, Dijkhuizen A, Sprong AGA. A case of extreme agitation and death after the use of mephedrone in the Netherlands. Forensic Sci Int. 2011;206:e93–5.PubMed
54.
Maher PJ, Walsh M, Burns T, Strote J. Prehospital resuscitation of a man with excited delirium and cardiopulmonary arrest. Can J Emerg Med. 2014;16:80–3.
55.
Mash DC, Staley JK, Izenwasser S, Basile M, Ruttenber AJ. Serotonin transporters upregulate with chronic cocaine use. J Chem Neuroanat. 2000;20:271–80.PubMed
56.
McDaniel CH, Miotto KA. Gamma hydroxybutyrate (GHB) and gamma butyrolactone (GBL) withdrawal: five case studies. J Psychoactive Drugs. 2001;33:143–9.PubMed
57.
Menaker J, Farcy DA, Boswell SA, Stein DM, Dutton RP, Hess JR, et al. Cocaine-induced agitated delirium with associated hyperthermia: a case report. J Emerg Med. 2011;41:e49–53.PubMed
58.
Miller C. A restraint asphyxia “near-death” case study. Restraint Asphyxia Newz Dir. 1998;1998:1–17.
59.
Mirchandani H, Rorke L, Sekula-Perlman A, Hood I. Cocaine-induced agitated delirium, forceful struggle, and minor head injury. Am J Forensic Med Pathol. 1994;15:95–9.PubMed
60.
Morrison A, Sadler D. Death of a psychiatric patient during physical restraint. Excited delirium - a case report. Med Sci Law. 2001;41:46–50.PubMed
61.
Murphy CM, Dulaney AR, Beuhler MC, Kacinko S. “Bath salts” and “plant food” products: the experience of one regional US poison center. J Med Toxicol. 2012;9:42–8.PubMedCentral
62.
Murray BL, Murphy CM, Beuhler MC. Death following recreational use of designer drug “bath salts” containing 3,4-Methylenedioxypyrovalerone (MDPV). J Med Toxicol. 2012;8:69–75.PubMedPubMedCentral
63.
O’Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol. 1993;14:289–95.PubMed
64.
O’Halloran RL, Frank JG. Asphyxial death during prone restraint revisited: a report of 21 cases. Am J Forensic Med Pathol. 2000;21:39–52.PubMed
65.
Park K, Korn C, Henderson SO. Agitated delirium and sudden death: two case reports. Prehospital Emerg Care. 2001;5:214–6.
66.
Penders TM, Gestring RE, Vilensky DA. Intoxication delirium following use of synthetic cathinone derivatives. Am J Drug Alcohol Abuse. 2012;38:616–7.PubMed
67.
Pestaner JP, Southall PE. Sudden death during arrest and phencyclidine intoxication. Am J Forensic Med Pathol. 2003;24:119–22.PubMed
68.
Plush T, Shakespeare W, Jacobs D, Ladi L, Sethi S, Gasperino J. Cocaine-induced agitated delirium: a case report and review. J Intensive Care Med. 2015;30:49–57.PubMed
69.
Pritchard A, Le Cong M. Ketamine sedation during air medical retrieval of an agitated patient. Air Med J. 2014;33:76–7.PubMed
70.
Rayamane A, Thejaswi H, Pradeepkumar M, Patra AP, Shaha KK. Case-series on death of physically restrained patients in de-addiction centers due to excited delirium syndrome. JIST. 2015;11:34–7.
71.
Reichmuth P, Blanc AL, Tagan D. Unintentional baclofen intoxication in the management of alcohol use disorder. BMJ Case Rep. 2015;Online Pub:1–3.
72.
Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome. Am J Forensic Med Pathol. 1999;20:120–7.PubMed
73.
Samuel E, Williams RB, Ferrell RB. Excited delirium: consideration of selected medical and psychiatric issues. Neuropsychiatr Dis Treat. 2009;5:61–6.PubMedPubMedCentral
74.
Scaggs TR, Glass DM, Hutchcraft MG, Weir WB. Prehospital ketamine is a safe and effective treatment for excited delirium in a community hospital based EMS system. Prehosp Disaster Med. 2016;31:563–9.PubMed
75.
Schiavone S, Neri M, Mhillaj E, Pomara C, Trabace L, Turillazzi E. The role of the NADPH oxidase derived brain oxidative stress in the cocaine-related death associated with excited delirium: a literature review. Toxicol Lett. 2016;258:29–35.PubMed
76.
Shields LBE, Rolf CM, Hunsaker JC. Sudden death due to acute cocaine toxicity-excited delirium in a body packer. J Forensic Sci. 2015;60:1647–51.PubMed
77.
Śliwicka O, Szatnera K, Borowska–Solonynko A. Three postmortem case reports of the excited delirium syndrome – A short comparison. J Forensic Leg Med. 2019;66:134–7.PubMed
78.
Stratton SJ, Rogers C, Green K. Sudden death in individuals in hobble restraints during paramedic transport. Ann Emerg Med. 1995;25:710–2.PubMed
79.
Sztajnkrycer MD, Baez AA. Cocaine, excited delirium and sudden unexpected death. Emerg Med Serv. 2005;34:77–81.PubMed
80.
Wiebe T, Sigurdson E, Katz L. Angel’s trumpet (Datura stramonium) poisoning and delirium. Paediatr Child Heal. 2008;13:193–6.
81.
Cole JB, Klein LR, Nystrom PC, Moore JC, Driver BE, Fryza BJ, et al. A prospective study of ketamine as primary therapy for prehospital profound agitation. Am J Emerg Med. 2018;36:789–96.PubMed
82.
Ezaki J, Ro A, Hasegawa M, Kibayashi K. Fatal overdose from synthetic cannabinoids and cathinones in Japan: demographics and autopsy findings. Am J Drug Alcohol Abuse. 2016;42:520–9.PubMed
83.
Grant JR, Southall PE, Mealey J, Scott SR, Fowler DR. Excited delirium deaths in custody: past and present. Am J Forensic Med Pathol. 2009;30:1–5.PubMed
84.
Gray SD, Fatovich DM, Mccoubrie DL, Daly FF, Medical T. Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation. Med J Aust. 2007;186:336–9.
85.
Ho JD, Heegaard WG, Dawes DM, Natarajan S, Reardon R, Miner JR. Unexpected arrest-related deaths in America: 12 months of open source surveillance. West J Emerg Med. 2009;10:68–73.PubMedPubMedCentral
86.
87.
Michaud A. Restraint related deaths and excited delirium syndrome in Ontario (2004-2011). J Forensic Legal Med. 2016;41:30–5.
88.
Miner JR, Klein LR, Cole JB, Driver BE, Moore JC, Ho JD. The characteristics and prevalence of agitation in an urban county emergency department. Ann Emerg Med. 2018;72:361–70.PubMed
89.
Mo H, Campbell MJ, Lam SW, Wells EJ, Casserly E, Meldon SW. Ketamine safety and use in the emergency department for pain and agitation / delirium : A health system experience 2020;21:10–2.
90.
Ross DL. Factors associated with excited delirium deaths in police custody. Mod Pathol. 1998;11:1127–37.PubMed
91.
Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J Forensic Sci. 1997;42:14064J.
92.
Strote J, Walsh M, Auerbach D, Burns T, Maher P. Medical conditions and restraint in patients experiencing excited delirium. Am J Emerg Med. 2014;32:1093–6.PubMed
93.
Strote J, Hutson HR. Taser use in restraint-related deaths. Prehospital Emerg Care. 2006;10:447–50.
94.
Vilke GM, Mash DC, Pardo M, Bozeman W, Hall C, Sloane C, et al. EXCITATION study: unexplained in-custody deaths: evaluating biomarkers of stress and agitation. J Forensic Legal Med. 2019;66:100–6.
95.
96.
97.
98.
Barnett JH, Werners U, Secher SM, Hill KE, Brazil R, Masson K, et al. Substance use in a population-based clinic sample of people with first-episode psychosis. Br J Psychiatry. 2007;190:515–20.PubMed
99.
Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and positional asphyxia. Ann Emerg Med. 1997;30:578–86.PubMed
100.
Chan TC, Neuman T, Clausen J, Eisele J, Vilke GM. Weight force during prone restraint and respiratory function. Am J Forensic Med Pathol. 2004;25:185–9.PubMed
101.
Michalewicz BA, Chan TC, Vilke GM, Levy SS, Neuman TS, Kolkhorst FW. Ventilatory and metabolic demands during aggressive physical restraint in healthy adults. J Forensic Sci. 2007;52:171–5.PubMed
102.
Savaser DJ, Campbell C, Castillo EM, Vilke GM, Sloane C, Neuman T, et al. The effect of the prone maximal restraint position with and without weight force on cardiac output and other hemodynamic measures. J Forensic Legal Med. 2013;20:991–5.
103.
Metadata
Title
The role of restraint in fatal excited delirium: a research synthesis and pooled analysis
Authors
Ellen M. F. Strömmer
Wendy Leith
Maurice P. Zeegers
Michael D. Freeman
Publication date
01-12-2020
Publisher
Springer US
Published in
Forensic Science, Medicine and Pathology / Issue 4/2020
Print ISSN: 1547-769X
Electronic ISSN: 1556-2891
DOI
https://doi.org/10.1007/s12024-020-00291-8

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