The Acutely Agitated Patient

FigureAuthor 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: Describe the clinical issues involved in sudden unexpected death of restrained delirious patients. Identify the physiological issues involved in sudden unexpected death of restrained delirious patients. 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.Figure: When confronted with a raving, lunatic patient in the ED, hellbent on gouging out your eyes, Dr. Roberts notes that you want Mercy Hospital Security Officer Brian Glenn, the quintessential Herculean burly security guard, to be your best friend. Once the patient is subdued, however, you do not want him compressing the rib cage of a prone hogtied patient who is still struggling to escape and soon will be acidotic, hyperthermic, and struggling to breathe. As soon as it's safe, substitute your favorite rapidly active sedative for the previously applied brutane.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 a of police and considers the when cannot even be cocaine use, and methamphetamine use are well known to to The nature of the deaths to acidosis rather than or as a primary you have not seen an acute and disease in a who previously healthy as a you have not of Custody Restraint and et al Am J Med These one a well in this area, have previously the restraint position and with regard to excited delirium. that body position chest and to a that an individual is at risk for and respiratory the was and has in the Although one that a type of restraint will respiratory and cardiac this has not been proven to be a lethal scenario for sudden death in This article case reports of custody deaths in hogtied as well as medical and physiological related to and in this specific position. It's well It has been that restraint chest and and The to the chest and the on and have been to cause respiratory This simply has not been but it is a common and a common litigation factors certainly include drug hyperthermia, and in addition to body In some have that the hobbled or hogtied position not be expected to be even it is a by on healthy have some data, but from such can be has been a largely by a study the of restraints and and heart in healthy J Med healthy individuals were hogtied after on a to a heart of When with the sitting position, in the restraint position had after in heart and on these findings, the authors that the deaths occurred in the hogtied position because of physiological respiratory of body position. They also that the prone position chest and and and the patient at risk for and of this study included the fact that the was by a inaccurate method of during This study is in other as Although other have of restraints on vital forced and have not been to death. In these authors conclude that factors other than body positioning appear to be more important of sudden unexpected death in restrained delirious patients. The use of stimulant drugs, underlying heart disease cardiopulmonary hyperthermia, and are to be more important factors than Although restraints in will cause some physiological there is no evidence that body positioning even in the hogtied position, or respiratory to asphyxia. Comment: This article the common and that merely a patient and him prone places him in a of sudden unexpected death. Such a position cause some physiological in the and but cannot sudden death. such is quite for the but it's often on the study a rather however, significant derangements of the cardiopulmonary during restraint, in an Six healthy who had not were prone or in a hobble restraint position for a derangements in were found in the prone position, with the in the prone position mean forced vital and forced by by heart by 21 blood pressure and cardiac by This has not been but it is I these data almost impossible to In a study J Med healthy in with no restraints or with the The levels and heart rates did not and the conclusion was that restraint the body did not cardiopulmonary in struggling and individuals. Of course, there have been no in drugged, delirious, and individuals who also have cardiac disease. I will the that having people on your while you are violently struggling is a and your but the position alone does not Although these deaths make the the is extremely the number of agitated patients who restraint on a basis. It's an unusual when an EP does not four or five burly police or in a raving lunatic with a history of having while being restrained for of Most of sudden cardiac death under these When do death is attributed to usually by law enforcement Medical especially the EP, not on the Once the patient is in the ED, it's time for drugs to do the of the although this is also only an attractive with regard to could that a patient is a because it can the for sudden cessation of physical allow acidosis to because cardiac be All in there are a of be of these issues. All of will likely be faced with such The with regard to is that the of chest and the of life-threatening by any position used by law enforcement is simply not of an to in sudden death by the of should not the of underlying heart disease and drug It is that restrained individuals hyperthermic, and when struggling against restraints, but they suddenly struggling and die is still a to the and sagacious EP to be a and should such patients with the that a could be just the The challenge to law enforcement officers, EMS and even the security staff is to often in a scenario where but drugs or physical restraints can control the situation. Unfortunately, only the EP has the drugs, an attractive yet still theoretical to be I conclude that it is best to for drugs, but it does the requisite restraints to the patient in of your sedation to with the patient has not been I with a of but that is also just so will one can intervene and at control of the and hopefully a are to specific and or on are will be in a to Dr. Roberts on this month's especially with and Deaths in delirious restrained patients usually have associated and metabolic acidosis, but the exact contribution of these parameters cause and is and physical during to escape or associated violent behavior prior to restraint will cause metabolic and other stimulants are invariably associated with sudden death during restraint, and a contribution of these cannot be A significant number of individuals who die during excited delirium have underlying cardiac disease, unexpected because of of history or young some to stimulant abuse While the prone and hobble restraint position this is likely not to be other are present as cardiac disease, hyperthermia, and When it's best to compression of the chest while Most individuals who are delirious and restrained do not sudden death, and it is The majority of are associated with factors that are unknown or cannot be controlled or altered during the restraint The of rapid chemical restraint, while and has not been proven to

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