Arrest-related death on the basis of a drug-induced excited delirium syndrome

In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review

Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration. To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement. In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself. After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.

Prone restraint death: Possible role of the Valsalva maneuver

There is an on-going debate about the safety of prone restraint and the exact role of the prone position in physical restraint death. Cardiac arrest in prone restraint death is essentially the end-result of a violent physical altercation wherein a combative individual suddenly loses consciousness while trying to counteract an opposing force. The direct correlations of increased static weight force with decreased inferior vena cava diameter, decreased cardiac output, and decreased stroke volume in prone restraint studies suggest that decreased venous return and decreased cardiac output could have a significant role to play in prone restraint death. Although the degree of changes observed in those studies might not be sufficient to cause cardiac arrest, they could predispose people who instinctively try to free themselves of the restraints to severe complications. The Valsalva maneuver, or forceful expiration against a closed airway, is frequently performed spontaneously in daily activities involving straining and resistance exercise, but has never been considered in restraint death. Pre-existing diminished venous return could increase the risk of major complications in individuals performing the Valsalva maneuver. A substantial decrease in venous return and cardiac output could increase the risk of cerebral hypoperfusion, loss of consciousness, hypoventilation, and sudden death. By increasing the risk of increased intra-abdominal pressure and its negative effect on venous return, high body mass index may be a significant risk factor in prone restraint death. The Valsalva maneuver may have different roles in prone restraint cardiac arrest and might be overlooked in prone restraint death.

Acute behavioural disturbance: recognition, assessment and management

Acute behavioural disturbance (ABD) is a clinical emergency which typically affects overweight men in their mid-thirties who chronically misuse illicit stimulants. People with ABD are most likely to be seen in police custody or emergency departments, therefore nurses working in these areas must be able to recognise the signs and symptoms and know how to respond appropriately. Presentation varies, but the signs and symptoms commonly include extreme agitation, hyperthermia, hostility and exceptional strength without fatigue. Further, it is important to recognise that people with ABD are at risk of developing metabolic acidosis, hyperkalaemia, rhabdomyolysis or disseminated intravascular coagulation. This article gives an overview of ABD and describes the main elements of management and treatment.