Letters

Acute excited states and sudden death

BMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7138.1171 (Published 11 April 1998) Cite this as: BMJ 1998;316:1171

Death after restraint can be avoided

  1. Derrick Pounder, Professor of forensic medicine
  1. Department of Forensic Medicine, University of Dundee, Royal Infirmary, Dundee DD1 9ND
  2. City and County of San Francisco, Hall of Justice, San Francisco, California CA94103, USA

    EDITOR—Farnham and Kennedy's recent editorial on sudden death in patients with acute psychiatric illness1 who are being restrained does not reflect the forensic literature fairly. It omits evidence from key publications 2 3 and twice misattributes statements to a paper that specifically excluded such deaths from the reported study.4

    The current consensus on “restraint asphyxiation” is reflected in a guidance statement of the United States Department of Justice.5 Any person who is restrained prone has trouble breathing when pressure is applied to his or her back or when handcuffed and “hog tied,” 2 3 and obesity exacerbates this. People's natural reaction is to struggle more violently, which may be met with still more restraining force, resulting in greater oxygen deficiency and, in some cases, death. Risk factors include any condition, such as ischaemic heart disease or excited delirium,2 that increases susceptibility to cardiac arrhythmias, as well as intoxication with alcohol or drugs.

    Recommendations given to police officers on how to prevent such deaths include releasing people from the prone position as soon as they are handcuffed, not sitting on them, and never tying handcuffs to a leg or ankle restraint (hog tying).5 A form of hog tying restraint known as the police leg lock was prohibited in Denmark in 1994, after a campaign by the human rights organisation Amnesty International when an incident had left an 18 year old permanently brain damaged. There is evidence that restraint procedures that compromise respiratory movements are potentially dangerous, and this needs to be taken into account in any debate on their use in a healthcare setting.

    References

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    Acute excited states are not caused by high blood concentrations of cocaine

    1. Steven B Karch, Assistant medical examiner,
    2. Boyd G Stephens, Chief medical examiner
    1. Department of Forensic Medicine, University of Dundee, Royal Infirmary, Dundee DD1 9ND
    2. City and County of San Francisco, Hall of Justice, San Francisco, California CA94103, USA

      EDITOR—Much more is known about acute excited states and sudden death than Farnham and Kennedy's editorial suggests.1 Such states are not, as they say, commonly associated with high blood concentrations of cocaine—subjects do not have high concentrations of cocaine. In 45 cases in Miami, concentrations were similar to those seen in asymptomatic recreational users.2 In people whose deaths are related to cocaine, whether due to psychosis or not, blood concentrations completely overlap those of people whose death was from trauma with cocaine as an incidental finding.3

      Neurochemical abnormalities have been identified. There are fewer D2 receptors in the centres of the hypothalamus that oppose D1 mediated temperature increases.4 This explains why those who die are invariably hyperthermic. In the series from Miami, mean body temperature was 40.6°C at the time of the first medical examination.2 Changes induced by cocaine in the number and distribution of κ2 opiate receptors within the amygdala may explain the distinctive psychotic symptoms and violent agitation.5 These changes can be shown at any neurochemistry reference laboratory, provided the brain is removed and slices frozen within 12 hours. The mere presence of these changes does not prove that police misconduct or medical mismanagement did not occur, but it does prove that the patient had a disease that is usually fatal.

      Death is often attributed to capsicum (pepper spray) poisoning rather than to the underlying psychiatric state. In trying to spray agitated psychotic people, police officers often miss their face and spray their back or shoulder and sometimes the faces of other officers. We use saline swabs to recover capsicum from skin and clothing of people who are alive and methanol to recover it from those who have died. There are no assays for capsicum in biological matrices, but toxicity is effectively ruled out if capsicum cannot be recovered from the facial area.

      Prudent management also includes a meticulous, well photographed, neck dissection to rule out neck compression, and measurement of drug concentrations in the brain. These seem to provide an accurate picture of the pattern of cocaine use, and the use at the time of death, whereas blood measurements are often unreliable.

      Finally, protocols must be put in place to ensure that all the appropriate measures are immediately taken. These are high profile cases. Since “popular journalism favours controversy and blame rather than balance and exploration,”1 it is probably a good idea to implement such protocols before the backlog of cases gets too large.

      References

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      View Abstract

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