Blood Born Infections Substance Misuse Associated Behaviours Positional Asphyxia Excited Delirium

1. Associated Risks Within Restraint • Blood Born Infections • Substance Misuse Associated Behaviours • Positional Asphyxia • Excited Delirium NCRGSA

2. Associated Risks Within Restraint • 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. NCRGSA

3. Associated Risks Within Restraint • 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. NCRGSA

4. Associated Risks Within Restraint • 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. NCRGSA

5. POSITIONAL ASPHYXIA NCRGSA

6. 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. NCRGSA

7. 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. NCRGSA

8. 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! 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. NCRGSA

9. POSITIONAL ASPHYXIA 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. 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. NCRGSA

10. What are the risk factors 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. Prescribed Drugs Position during restraint Respiratory disorders Prolonged struggle Drug & Alcohol intoxication Cardiovascular disorders Obesity NCRGSA

11. Vicious Circle Violent muscle activity Increased 0 demand Incident of Restraint Muscle weakness 2 Hypercatabolic state Stress on heart Respiratory muscle energy deficit NCRGSA

12. How Can You Asphyxiate ? 1. Direct neck compression 2. Chest or back torso compression 5. Postural / Position 3. Airway obstruction/vomitus 4. Environmental / Chemicals NCRGSA

13. Positional 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. This can be defined when the position of a persons body interferes with respiration resulting in death from asphyxia. NCRGSA

14. 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 NCRGSA

15. Carida Arrhythmia 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). NCRGSA

16. Signs of Asphyxia Congestion of the face Facial Oedema Cyanosis/excess de-oxygenated heamaglobin (blood). NCRGSA

17. Be Aware 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. NCRGSA

18. WHAT YOU SHOULD NOT DO State the Dangers NCRGSA

19. 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. To Summarize 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) NCRGSA

20. Excited Delirium NCRGSA

21. Definition Excited delirium is a rare form of SEVERE MANIA sometimes part of the spectrum of manic-depressive psychosis and chronic schizophrenia NCRGSA

22. Excited Delirium Also known as: • Agitated delirium • Cocaine induced psychosis • Acute exhaustive mania NCRGSA

23. It is characterised by purposeless, often violent activity coupled with incoherent or often meaningless speech and hallucinations with paranoid delusions NCRGSA

24. Excited Delirium Can Be Caused By • Psychiatric illness • (combined with Drink and/or Drugs) • Drug intoxication • (Cocaine is the best known cause of excited Delirium) • Alcohol NCRGSA

25. Effects of Excited Delirium Hypothermia is often associated with this syndrome High tolerance to pain Quick to fatigue – especially after a violent struggle Skin may be hot to touch Abnormal Strength NCRGSA

26. Symptons of Excited Delirium A diminished sense of pain Sudden tranqullity after freinzied activity Violent towards others Unexpected physical strength Sweating, fever, heat intolerance NCRGSA

27. Before a struggle During a struggle Death Can Occur During restraint After restraint NCRGSA

28. Identifying Excited Delirium • Bizarre and or aggressive behaviour • Impaired thinking • Disorientation • Hallucinations • Acute onset of paranoia • Shouting NCRGSA

29. BE AWARE OF Pulse rate Breathing Temperature Sudden Passivity NCRGSA

30. A Case Study of Excited Delirium • A 25 year old male • Weighing 72kg, 176cm high, • Healthy, tall and lean. • He had psychiatric disturbed behaviour since the age of 14 • Presented with erratic an violent behaviour. • Diagnosed with Schizophrenia and Hypomania at the age of 17. • He had a number of hospital admissions. • History of drug abuse. • Using amphetamines, LSD, cannabis, and also anabolic steroids. • History of violence. NCRGSA

31. A Case Study of Excited Delirium 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. NCRGSA

32. A Case Study of Excited Delirium 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. NCRGSA

33. A Case Study of Excited Delirium 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. NCRGSA

34. A Case Study of Excited Delirium 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. NCRGSA

35. A Case Study of Excited Delirium 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…….. NCRGSA

36. A Case Study of Excited Delirium pronounced DEAD. At 11.50 pm NCRGSA

37. A Case Study of Excited Delirium 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. NCRGSA

38. A Case Study of Excited Delirium • 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. NCRGSA

39. A Case Study of Excited Delirium 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 NCRGSA

40. A Case Study of Excited Delirium 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. NCRGSA

41. A Case Study of Excited Delirium 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) NCRGSA

42. Any Questions ? NCRGSA