The role of restraint in fatal excited delirium: a research synthesis and pooled analysis
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REVIEW
The role of restraint in fatal excited delirium: a research synthesis and pooled analysis Ellen M. F. Strömmer 1
&
Wendy Leith 1 & Maurice P. Zeegers 1 & Michael D. Freeman 1
Accepted: 23 July 2020 # The Author(s) 2020
Abstract The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death. Keywords Excited delirium . Agitated delirium . Restraint asphyxia . Choke hold . Epidemiology
Introduction Excited delirium syndrome (ExDS) is a diagnostic term used to characterize a potentially fatal state of extreme agitation and delirium, often combined with aggressive behavior, tolerance to pain, extreme physical strength and endurance, and hyperthermia [1–4]. The typical presentation of an individual diagnosed with ExDS is a man in his thirties, who 1) died while in a state of agitation and delirium, 2) had a history of drug abuse or mental illness, 3) recently used a stimulant drug such as methamphetamine or cocaine, and 4) was physically restrained at the time of death, most commonly by law enforcement personnel [5]. Because there are no autopsy findings that
* Ellen M. F. Strömmer [email protected] 1
CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
indicate ExDS, and intoxicant levels in the bodily fluids are typically at a recreational rather than a fatally toxic level, the diagnosis is one of exclusion [6, 7]. The concept of delirium leading to
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