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Blood Born Infections Substance Misuse Associated Behaviours Positional Asphyxia Excited Delirium

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HIV rates amongst injecting drug users are low 1 – 2% needle stick injuries transmit infection.

Be aware of unsheathed needles about the person that can pass on HIV and hepatitis.

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Some substances of misuse can induce paranoia stimulants such as amphetamine, cocaine, crack cocaine and cannabis can induce paranoia.

Anabolic steroids to can cause paranoia and irritability and unfortunately lots of muscles too.

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Hepatitis rates are high up to 50% of drug users.

If you come into contact with any fluids from service users you should be vaccinated against the risks, and cover any open wounds you may have as a matter of course.

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The term asphyxia is thought by some forensic pathologists to be a vague and confusing term, but it refers to a state in which the body becomes deprived of oxygen while in excess of carbon dioxide i.e hypoxia.

This state can result in loss of consciousness and/or death.

Prior to any death the body usually reaches a low oxygen high carbon dioxide state.

So asphyxia death is therefore one in which the oxygen deprived state has been achieved unnaturally.

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Extreme physical energy expenditure generates excessive

production of adrenalin and noradrenalin.

A progressively increasing amount of these body chemicals

in the individuals system can occur creating a

“hyper- catabolic state”.A hyper-catabolic state can weaken all the body's muscles

especially the

Respiratory muscles.

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The hyper-catabolic state also puts “stress” on the heart by increasing its workload

(requiring faster and stronger contractions).

Thus the heart needs more than normal amounts of oxygen in order to keep it

functioning.If an individual with severe respiratory muscle fatigue is restrained in a position that

impairs or prevents breathing it is easy to understand why asphyxia

can occur so quickly!

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Positional asphyxia or Traumatic Asphyxia is a syndrome, which may be the sole or contributory factor in death, which may occur as a result of restraint being used.

Breathing is a mechanical process involving the chest wall, rib cage, diaphragm and abdominal muscles, and if the movement of all, or any of these are significantly impaired for any length of time, then death may occur.

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Positional asphyxia has been associated with a number of deaths during physical restraint, more usually during mechanical restraint but also during ‘hands on’ techniques, which physically restrict the person’s freedom of movement.

The available evidence suggests that a combination of factors may place individuals at a higher risk.

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Positional AsphyxiaThis can be

defined when the position of a

persons body interferes with

respiration resulting in death from

asphyxia.

Any body position that obstructs the airway or that interferes with the muscular or mechanical components of respiration (intercostals muscles, diaphragm etc) may result in positional asphyxia.

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Along with the major factors within positional or

traumatic asphyxiation.

We can also face additional risks if pressure

is placed to the neck/carotid artery

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This is a controversial postulated mechanism where by the pressure

over the carotid artery at the carotid sinus provokes a reflex,

slowing down the heart ,which may provoke a fatal arrhythmia.

(Particularly in the elderly and those with underlying cardiac

disease).

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Individual needs to be observed, watching vital signs for overheating and/or dehydration.

Care and attention is vital, especially where the

patient / client is secluded or left resting in bed.

If the individual is sleeping, the recovery position should be effected ASAP.

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State the Dangers

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No pressure is to be put onto the individual’s torso during any restraint.

Heart rate, respiration and body temperature can be affected

during restraint.After restraint vital signs must be observed if there is any indication of risk.

Caution must be observed in administering medication.

(Look at Guidelines & Protocols within your own Clinical Area)

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Definition

Excited delirium is a rare form of SEVERE MANIA sometimes

part of the spectrum of manic-depressive psychosis and

chronic schizophrenia

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Also known as:

Agitated delirium

Cocaine induced psychosis

Acute exhaustive mania

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It is characterised by purposeless, often violent

activity coupled with incoherent or often meaningless speech and

hallucinations with paranoid delusions

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•Psychiatric illness

(combined with Drink and/or Drugs)

•Drug intoxication

(Cocaine is the best known cause of excited Delirium)

•Alcohol

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Abnormal Strength

High tolerance to pain

Skin may be hot to touch

Quick to fatigue – especially after a violent struggle

Hypothermia is often associated with this syndrome

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Before a struggle

During a struggle

During restraint

After restraint

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o Bizarre and or aggressive behaviour

o Impaired thinking

o Disorientation

o Hallucinations

o Acute onset of paranoia

o Shouting

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o A 25 year old male

o Weighing 72kg, 176cm high,

o Healthy, tall and lean.

o He had psychiatric disturbed behaviour since the age of 14

o Presented with erratic an violent behaviour.

o Diagnosed with Schizophrenia and Hypomania at the age of 17.

o He had a number of hospital admissions.

o History of drug abuse.

o Using amphetamines, LSD, cannabis, and also anabolic steroids.

o History of violence.

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At 1.30 am

He was assaulted by six bodybuilders in a pub car park. He became violent and aggressive, stripped to the waist, and ran through the streets punching and kicking car doors and windows, causing damage. He was chanting. The police were called and he was arrested by two police constables. He had sustained cuts to his wrist and was smeared in blood. He was able to escape from the grasp of the police and ran away. He was caught again and struck twice with a baton, wrestled to the ground, and then got up and ran away again. At the third arrest he was wrestled to the ground by seven police officers. He was handcuffed with his hands behind his back, pinned face down in the police van, and a police officer sat on his legs.

At 2.00 am

He was carried into the cells and handcuffed.

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During this time he remained agitated and aggressive and continued to chant.

At 2.45 am

The police surgeon was called but could not get near the individual due to his violent behaviour. He was observed through the hatch. The police surgeon felt he was in an acute state of drug intoxication, however he was fit to be detained. He remained agitated throughout the night on and off.

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At 8.35 am

The following morning he was seen by the police surgeon. He was still distressed and sectioned under the Mental Health Act. He was seen by psychiatric nurses at this time.

At 10.40 am

He was given 200 mgs of Droperidol IV. He became calmer and was escorted on foot to the ward.

At 1.00 pm

He arrived on the ward.

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At 2.15pm

His forearm was sutured. He settled and slept briefly.

At 3.45 pm & 5.00 pm

200 mgs of Droperidol was given orally.

At 9.00 pm

He because agitated, exhibited threatening behaviour, spitting and swearing. He refused medication. He was restrained and carried on to a bed.

At 9.40 pm

Droperidol was administered.

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He was restrained for 90 minutes by five staff taking it in turn. He was positioned on his right side with both legs on the bed. He was held with his right arm drawn down on the bed. Neck holds were used at various stages. Chlorpromazine 50 mgs was given.

At 11.00 pm

He calmed down, the restraint was released and he began to sleep.

At 11.20 pm

He was checked. His colour was poor and there was no pulse. He had suffered a cardiac arrest. Resuscitation continued, and he was……..

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pronounced

DEAD.

At 11.50 pm

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The results of the post-mortem and the evidence which had been gathered showed that:-

He was pinned down by his right hand and held down by two individuals, one leaning across his chest with his pelvis twisted.

His injuries were broken down into specific and non-specific.

There were abrasions and bruises on his face, torso, limbs and knuckle.

There were counter pressure abrasions on his back, minor injuries on his face, and minor injuries to the back, minor

injuries on his face, and minor injuries to the body.

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The bruises to the right shoulder were as a result of baton blows

Cuts to the wrist could be attributed to the two handcuffs.

Cuts to forearms due to breaking glass.

These injuries ere all attributed while in police custody.

The injuries that could be attributed during restraint were bruises to the

inside left of the arm.

Bruises to the left chest wall.

Underlying muscular bruising.

Rib injuries.

Dislocation and rib fractures.

A pattern of a jumper weave on the chest could be matched to the individual

restraining.

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There were also bruises on the chest. All rib injuries occurred at the same time, therefore

indicating an arm across the chest. There were no head or neck injuries, no facial or

internal traumas. There was no single cause of death.

Toxicology showed Paracetamol but no evidence of drug abuse

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The factors that contributed to the death. Exhaustion, lactic, acidosis, twisted position of

torso, pinning of the chest, rib injuries and neck holds.

In excited delirium the adrenaline produced can be toxic to the heart and can produce a

cardiac arrhythmia. This would result in hypoxia, exaggerated acidosis, all of which are factors that would cause cardiac arrest.

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The fatal accident inquiry, which was held in Scotland, found no criticism, of the police and accepted that a safe position of restraint was required. The restraint on the bed within the

psychiatric hospital was found not to have contributed to the death. Restraint on a hard surface

would have greater injuries with counter pressure injuries. The injuries could, however, be attributable to being restrained on the bed due to the fact that

they were on one side. This is not to say that restraint on the floor is more dangerous as it may give better access to those undertaking restraint.

Dr David Sadler,

Senior Lecturer in Forensic Medicine,

Department of Forensic Medicine,

Dundee University (1999)

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