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Alcohol, drugs, toxins and post-mortem toxicology
Published in Helen Whitwell, Christopher Milroy, Daniel du Plessis, Forensic Neuropathology, 2021
Colin Smith, Christopher Milroy
Excited delirium (ED) is a clinico-pathological condition that presents to emergency medicine specialists and forensic pathologists (Gill 2014). It involves an agitated person with often violent, disordered and bizarre behaviour who by their behaviour often comes into contact with law enforcement agencies and healthcare professionals. Typically there is drug intoxication with a stimulant drug, most frequently cocaine and methamphetamine, but is also associated with psychiatric disorders. It is more common in warm weather and hyperpyrexia is a feature. It may be fatal and, when there has been engagement with law enforcement officers, controversial. Sudden death may occur during restraint, and the autopsy often fails to disclose a cause of death.
Positional Traumatic and Restraint Asphyxia
Published in Burkhard Madea, Asphyxiation, Suffocation,and Neck Pressure Deaths, 2020
In the individuals involved, excited delirium was most often caused by a psychiatric disorder, but it was also frequently induced by psychoactive stimulative drugs, in particular cocaine (Table 23.3, Figure 23.5) [9,11,16]. Cocaine causes excessive sympathetic activation by blocking presynaptic uptake of catecholamines, dopamine and serotonin, resulting in increased myocardial contractility, blood pressure and heart rate. Coronary artery vasoconstriction, increased microvascular resistance and enhanced thrombogenicity of the blood may be associated with myocardial ischaemia [14].
Police custodial healthcare
Published in Jason Payne-James, Richard Jones, Simpson's Forensic Medicine, 2019
Jason Payne-James, Richard Jones
Unexpected deaths periodically occur in individuals held in police custody. These decedents have usually had significant physical exertion associated with violent and/or bizarre behaviour, have been restrained by the police, and often have drug intoxication. An autopsy in such cases may not provide a satisfactory explanation for the cause of death, and these deaths may then be attributed to the excited delirium syndrome (ExDS), or an ‘acute behavioural disturbance’. The pathogenesis of excited delirium syndrome/acute behavioural disturbance-associated deaths is likely to be multifactorial and includes a variety of factors such as positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias.
Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only
Published in Prehospital Emergency Care, 2019
Laurel O’Connor, Matthew Rebesco, Conor Robinson, Karen Gross, Andrew Castellana, Mark J. O’Connor, Marc Restuccia
Prehospital providers are often faced with the task of managing and safely transporting patients who are agitated due to chemical, organic, or psychiatric pathologies. Combative patients pose a physical hazard to providers, and they put themselves at risk for accidental injury or complications associated with restraint (1, 2). Such complications have been described extensively in the prehospital literature and include asphyxiation, hyperthermia, heat stroke, and even death (3). Excited delirium syndrome (ExDS) can be exacerbated by physical restraint and is potentially lethal; it results in mortality with little warning if not appropriately identified and treated (4–6). Chemical restraints are recommended for all patients exhibiting signs or symptoms of ExDS for the safety of patients and providers (7). Chemical restraints do, however, have their own adverse effects and can cause complications even when administered in appropriate doses. Therefore, optimizing the effectiveness and safety of chemical restraint administration in the prehospital setting is vital for ensuring the safety of both providers and patients.
Reduced-dose intramuscular ketamine for severe agitation in an academic emergency department
Published in Clinical Toxicology, 2020
Michael E. O’Brien, Lanting Fuh, Ali S. Raja, Benjamin A. White, Brian J. Yun, Bryan D. Hayes
An ED guideline was implemented at our institution utilizing IM ketamine at a dose of 2 mg/kg (maximum 200 mg) for patients ≥18 years old with severe agitation, excited delirium, or agitation following a trauma. The presence of severe agitation or excited delirium was based on the emergency medicine provider’s clinical judgment. This dose can be repeated with an additional 2 mg/kg (maximum 200 mg) dose after 5 min, if necessary, to a cumulative maximum dose of 4 mg/kg (400 mg). Based on our guideline, IM ketamine can be used either as the initial sedating agent or as a subsequent treatment after the failure of another agent. An ongoing quality assurance process was conducted following each case to ensure no changes or updates to the guideline were required.