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 Asphyxia
This 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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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
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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,
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Dundee University (1999)
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