Acute Excited States
and Sudden Death

AUTHORS: Frank R Farnham, Lecturer in forensic psychiatry;
Henry G Kennedy, Consultant forensic psychiatrist

An Editorial Letter
Published in the, British Medical Journal
BMJ November, 1997;315:1107-1108

(I'm not going to correct their spelling errors – since BMJ didn't, either!

Much journalism, little evidence

Excited delirium is a state of mental and physiological arousal, agitation, hyperpyrexia with epiphora, and hostility. Observers typically emphasise the extreme sweating, bizarre behaviour and speech, and the subject's extraordinary strength and endurance when struggling, apparently without fatigue. Such states are commonly associated with high blood concentrations of cocaine or other stimulants, though some cases arise in those with histories of schizophrenia or mania and no evidence of intoxication.(1) The same syndrome was, however, described under various names long before drug abuse was prevalent, and was recognised for its high mortality.(2) Such deaths, often in police custody or other highly charged situations, commonly give rise to high profile coroner's hearings and inquiries.(3)

In the era before neuroleptics death in such agitated states was attributed to exhaustion, though neuroleptic malignant syndrome and the cardiac effects of neuroleptics now often enter into consideration, as does the effect of substance abuse.(4, 5) At necropsy often no anatomically obvious cause is found. It has been suggested that restraint in the prone position, with the subject often "hog tied" with handcuffs behind the back and ankles shackled, causes splinting of the respiratory apparatus and respiratory muscle fatigue, with death due to positional asphyxia.(1) Published cases seldom show petechiae or other pathognomonic evidence of asphyxia, so this suggestion must be treated with caution. A cycle of alternating struggle and relaxation is commonly observed before collapse and cardiac arrest, particularly when the person is restrained.

Collapse can occur in acute excited states such as mania and catatonic excitement because of a mental state in which agitation is centrally driven regardless of context, leading to physiological exhaustion without subjective fatigue. High circulating adrenaline concentrations, lactic acidosis, and dehydration contribute to a tendency towards ventricular tachyarrhythmias, while myocardial hypertrophy due to common disorders such as hypertension or diabetes mellitus or cocaine misuse (5) also increases the risk of cardiac arrhythmia. Neuroleptics and antidepressants can lengthen the QT interval, further increasing risk, though whether parenteral neuroleptics can be called causal in such diatheses seems unclear.(6, 7)

Although acute excited states have seldom been the subject of systematic research, they should be regarded as a medical emergency with a serious mortality. The medical and nursing management should aim to reduce confrontation by predicting and defusing situations that might arouse excited delirium, although such individuals can become extremely agitated with little provocation. When patients cannot cooperate and are at risk of dangerous behaviour to themselves or others, as well as exhaustion and collapse, the remaining therapeutic options are restraint, seclusion, and medication. Despite recent criticism of seclusion,(8) this may be the safest and most dignified intervention, especially if there are concerns arising from the patient's medical or psychiatric history. Best practice should draw on all three as appropriate, and to eliminate any one would increase the risk from excessive use of those remaining. There is evidence that in prolonged excited states, electroconvulsive therapy is safe and effective.(2) Exact diagnosis is important if treatable organic states are not to be missed, and those with neuroleptic malignant syndrome should clearly not receive more antipsychotic medication.

Staff in accident and emergency departments, psychiatric reception clinics, police stations, and prisons are all at risk of criticism when episodes of excited delirium end in death, even though criticism may arise from errors of inference. Legal reasoning favours single proximate causes rather than medical conditions, but the intervention most proximate to the time of death is not necessarily the cause of death. Similarly, popular journalism favours controversy and blame rather than balance and exploration. Scientifically derived clinical practice in such emergencies is likely to develop only in adequately staffed and skilled psychiatric intensive care units, not as a result of well publicised, but ultimately anecdotal, reports and inquiries about individual cases. Ready access to psychiatric intensive care units would do much to ensure that patients receive the best possible care in an environment which meets their needs.

Frank R Farnham, Lecturer in forensic psychiatry
Henry G Kennedy, Consultant forensic psychiatrist
Camlet Lodge Regional Secure Unit, Chase Farm Hospital, Enfield, Middlesex EN2 8JL

  1. Bell MD, Rao VJ, Weitli C, Rodriguez RN. Positional asphyxia in adults: 30 cases. Am J Foren Med Pathol 1992;13:101-7.

  2. Mann SC, Caroff SN, Bleier HR, Weiz WKR, Kling MA, Hayashida M. Lethal catatonia. Am J Psychiatry 1986;143:1374-81.

  3. Sheppard D. Learning the lessons: mental health inquiry reports published in England and Wales between 1969-1994 and their recommendations for improving practice. London: Zito Trust, 1994.

  4. Mirchandani HG, Rorke LB, Sekula-Perlman A, Hood IC. Cocaine-induced agitated delirium, forceful struggle, and minor head injury. A further definition of sudden death during restraint. Am J Foren Med Pathol 1994;15:95-9.

  5. Karch SB. Cardiac arrest in cocaine users. Am J Emerg Med 1996;14:79-81.

  6. Jusic N, Lader M. Post-mortem antipsychotic drug concentrations and unexplained deaths. Br J Psychiatry 1994;165:787-91.

  7. Dolan M, Boyd C, Shetty G. Neuroleptic induced sudden death – a case report and critical review. Med Sci Law 1995;35:169-74.

  8. Blom-Cooper L, Brown M, Dolan R, Murphy E. Report of the Committee of Inquiry into Complaints about Ashworth Hospital. Vol 1 and 2. London: HMSO, 1992.

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Death After Restraint Can Be Avoided

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