In-custody Deaths - Taser Presentation, NLETC, 2000
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National Law Enforcement Training Center July 2000 Annual Seminar In-Custody In-Custody Death Death Fabrice Czarnecki, M.D., M.A., M.P.H. Medical Advisor, National Law Enforcement Training Center 1 Case Case No No 11 History: 30 year old male standing in the middle of traffic, in a downtown street. A police officer offers to help the subject. The subject seems to ignore to officer. The subject punches the officer, when touched. The subject and the officer struggle, and the subject is restrained. The subject is brought to the hospital by the police for medical clearance. 2 Case Case No No 11 Diagnosis: Hypoglycemia Diabetes mellitus The subject’s mental status returns to normal after receiving sugar in the emergency department. The subject apologizes to the officer. No charges are brought. Graham v. Connor: Graham was suffering from hypoglycemia. Officers believed he was drunk, and refused to give him some sugar. 3 Case Case No No 22 30 year old female who is found agitated in a street by the police. EMS is called by the police. The subject is brought to the emergency department for confusion and hallucinations. She is cleared by the medical resident despite a low-grade fever (100.6 °F). The psychiatrist diagnoses a delusional disorder, calms her down with oral Haldol. The patient is discharged with a followup appointment. 4 Case Case No No 22 Three hours later, EMS brings her back for a more severe agitation. She is given an injection of Haldol. Then, the vital signs: Heart rate: 100 Blood pressure: 90/50 SaO2: 75% (normal > 95%) 5 Case Case No No 22 Chest X-ray: lobar pneumonia Diagnosis: Pneumonia (Streptococcus pneumoniae) Septicemia Septic shock The patient was intubated in the emergency department, and admitted to the intensive care unit. She was given high doses antibiotics, but died 6 hours later. 6 Case Case No No 33 30 year old male arrested for selling drugs. He is brought to the emergency department for medical clearance. No prior medical history. 7 Case Case No No 33 Vital signs: HR 140 BP 220/130 RR 28 T 103.2 Patient is very agitated. No other findings in the physical exam. 8 Case Case No No 33 The patient now admits to swallowing several bags of cocaine approximately 3 hours ago, when he was arrested. The patient receives nitroglycerin and benzodiazepines, activated charcoal and polyethylene glycol. The patient subsequently develops generalized seizure activity, increasing hyperthermia, rhabdomyolysis, and intracranial hemorrhage. He expires 24 hours after admission. 9 Causes Causes of of In-Custody In-Custody Death Death -11 Diseases with disturbed behavior: ► ► ► ► ► Excited delirium Intracranial bleeding Encephalitis/Meningitis Seizures Complications of diabetes (hypoglycemia and hyperglycemia) ► ► ► Hypoxia Toxic coma Metabolic coma 10 Causes Causes of of In-Custody In-Custody Death Death -22 Exacerbation of pre-existing diseases: ► Cardiovascular disease ► Intracranial hemorrhage ► Seizures ► Asthma ► Sickle cell trait Role of stress? (Lecomte, Forensic Sci Int 1996) 11 Causes Causes of of In-Custody In-Custody Death Death -33 Injuries: ► Suicide ► Accident ► Homicide (including asphyxia by neck compression or thoracoabdominal compression) 12 In-Custody In-Custody Death Death & & Excited Excited Delirium Delirium 13 Drugs Drugs of of Abuse Abuse DEA Classification: ► Narcotics ► Depressants ► Stimulants ► Cannabis ► Hallucinogens ► Anabolic Steroids 14 Drugs Drugs of of Abuse Abuse Narcotics: ► Heroin ► Morphine ► Codeine Effects of overdose include coma and death 15 Drugs Drugs of of Abuse Abuse Depressants: ► Barbiturates ► Benzodiazepines (Valium) Effects of overdose include coma and death 16 Drugs Drugs of of Abuse Abuse Stimulants: ► Cocaine ► Amphetamine/Methamphetamine ► Methylphenidate (Ritalin) 17 Drugs Drugs of of Abuse Abuse Cannabis: ► Marijuana ► Tetrahydrocannabinol ► Hashish 18 Drugs Drugs of of Abuse Abuse Hallucinogens: ► LSD ► Mescaline ► Psilocybin ► MDMA (Ecstasy) ► Phencyclidine (PCP) 19 Drugs Drugs of of Abuse Abuse Anabolic Steroids: ► Testosterone ► Nandrolone 20 LSD LSD (lysergic (lysergic acid acid diethylamide) diethylamide) Absorption: ► Oral (most commonly) ► Snorting ► Injection ► Smoking ► Conjunctival instillation Duration of effects: 6-12 hours 21 LSD LSD (lysergic (lysergic acid acid diethylamide) diethylamide) Complications: ► Seizures ► Panic attack ► Excited delirium ► Stroke (cerebral vasospasm) 22 Phencyclidine Phencyclidine (PCP (PCP -- phenylcyclohexylpiperidine) phenylcyclohexylpiperidine) Absorption: ► Smoking (most commonly), often mixed with marijuana ► Snorting ► Injection ► Oral 23 Phencyclidine Phencyclidine (PCP) (PCP) Complications: ► Agitation ► Hyperthermia ► Rhabdomyolysis and renal failure ► Seizures ► Excited delirium ► Coma Anticipate sudden violent acts: “Results showed that PCP use was related to increased levels of hostility...” (McCardle, Addict Behav 1989) 24 MDMA MDMA (Ecstasy) (Ecstasy) 3,4 3,4methylenedioxymethylamphetamine methylenedioxymethylamphetamine Absorption: ► Oral (most commonly) ► Snorting ► Injection Commonly used at rave parties 25 MDMA MDMA (Ecstasy) (Ecstasy) Complications: ► Agitation ► Dehydration with hyponatremia (diuretic effect) ► ► ► Hyperthermia Seizures Excited delirium 26 Amphetamines Amphetamines Types: ► Racemic amphetamine ► Dextro amphetamine (Dexedrine) ► Methamphetamine (crank, crystal, speed, ice) ► Over 14 different known drugs 27 Amphetamines Amphetamines Absorption: ► Oral (most commonly) ► Injection ► Smoking ► Snorting Duration of effects: 2-4 hours 28 Amphetamines Amphetamines Complications: ► Agitation ► Hyperthermia ► Rhabdomyolysis ► Excited delirium ► Cardiomyopathy 29 Cocaine Cocaine Absorption: ► Oral (most commonly) ► Injection ► Smoking ► Snorting ► Body packer Duration of effects: 1-2 hours 30 Cocaine Cocaine Cocaethylene: ► Potent active metabolite of cocaine + ethanol ► Duration of effects: up to 6 hours ► More active and more dangerous than cocaine 31 Cocaine Cocaine Complications: ► Agitation ► Hyperthermia ► Rhabdomyolysis ► Excited delirium ► Seizures ► Coma ► Cardiac complications 32 Cocaine Cocaine Sensitization ► Heightened response with chronic use (dopaminergic dysfunction) ► Probably the explanation of fatal excited delirium with “non-lethal doses” of cocaine (Ruttenber, J Forensic Sci 1997) 33 Cocaine Cocaine Mechanism of death: ► Excited delirium and hyperthermia ► Myocardial infarction ► Arrhythmia ► Seizures ► Coma ► Exacerbation of pre-existing diseases: - Cardiovascular disease - Intracranial hemorrhage 34 Combination Combination of of Drugs Drugs In a large London hospital A&E department, 50% of the patients who had taken Ecstasy also took another illicit substance, mainly amphetamines and cocaine. “The more serious complications of delirium, seizures, and profound unconsciousness (coma) were commoner when MDMA was used in combination with other substances.” (Williams, J Accid Emerg Med 1998) 35 Delirium Delirium Definition: Acute change in mental status characterized by impairment of attention. Diagnostic Criteria for Delirium (as defined by DSM-IV) A.Disturbance of consciousness (i.e., reduced clarity of awareness of environment) with reduced ability to focus, sustain, or shift attention. B.A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C.The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. Diagnostic and statistical manual of mental disorders, 4th ed. 36 Excited Excited Delirium Delirium Definition: Delirium with continuous agitation 37 Excited Excited Delirium Delirium Causes: ► Toxic Cocaine Amphetamines Ecstasy PCP LSD ► ► Drug withdrawal Psychosis (psychiatric disorder) 38 Excited Excited Delirium Delirium Complications: ► ► ► ► ► ► ► Hyperthermia Rhabdomyolysis Hyperkalemia Metabolic acidosis Renal failure Hypoxia Sudden death (arrhythmia) Comparable syndrome to the neuroleptic malignant 39 Excited Excited Delirium Delirium Early Management: ► CPR and defibrillation if necessary ► Sedation ► Cooling ► Restraints if necessary Increased mortality if patient is restrained (without adequate sedation). 40 Excited Excited Delirium Delirium Treatment: ► Sedation (benzodiazepines) ► Oxygen ► Cooling ► Hemodialysis 41 Positional Positional Asphyxia Asphyxia & & In-Custody In-Custody Death Death 42 Definitions Definitions Asphyxia: ► Extreme decrease in the amount of available oxygen in the body Two types: ► Mechanical ► Chemical (e.g., carbon monoxide) 43 Definitions Definitions Mechanical Asphyxia: ► Strangulation (application of force to the neck, not resulting from the weight of the victim’s body) ► Hanging (application of force to the neck, resulting from the weight of the victim’s body) ► ► ► Suffocation Positional asphyxia Drowning (death due to submersion) 44 Suffocation Suffocation Definition: Failure of oxygen to reach the blood 45 Suffocation Suffocation Five types: ► Depletion or displacement of oxygen and carbon dioxide accumulation (e.g., sealed container) ► Smothering (obstruction of the nose and mouth -- e.g., plastic bag) ► Choke (obstruction of the internal airway by a foreign object) ► Compression asphyxia (breathing hindered by external chest compression) ► Laryngeal edema (e.g., allergy) 46 Positional Positional Asphyxia Asphyxia Body upside down, flexed neck Usually associated with alcohol or drug intoxication 47 Sudden Sudden Death Death & & Restraints Restraints -- 11 Excited delirium Increased risk of sudden restrained (without sedation) death if Pollanen, CMAJ 1998 Pudiak, Life Sci 1994 Ross, Mod Pathol 1998 48 Sudden Sudden Death Death & & Restraints Restraints -- 22 ► Compression asphyxia Do not sit on the chest of a subject! ► Strangulation Bar arm choke hold 49 Hogtie Hogtie Position Position & & Positional Positional Asphyxia Asphyxia ► Does hogtying kill? ► Is it “positional asphyxia”? 50 Hogtie Hogtie Position Position & & Positional Positional Asphyxia Asphyxia Parkes (Med Sci Law 2000): ► Longer recovery time (heart rate) in a facedown position ► No significant changes in oxygen saturation Schmidt (J Emerg Med 1999): ► Comparison between hogtie and sitting positions after physical exertion. ► No significant differences in recovery heart rate and oxygen saturation between the two positions. 51 Hogtie Hogtie Position Position & & Positional Positional Asphyxia Asphyxia Chan (Ann Emerg Med 1997): ► Comparison between hogtie and sitting positions after physical exertion. ► Minor decline in pulmonary functions tests in the hogtie position. ► No significant difference in heart rate recovery, oxygen saturation and PCO2 between the two positions. 52 Hogtie Hogtie Position Position & & Positional Positional Asphyxia Asphyxia Hogtying does not appear to cause significant respiratory compromise. Hogtying does asphyxia”. not constitute “positional Sudden deaths in the hogtie position are probably caused by excited delirium. 53 Taser Taser and and In-Custody In-Custody Death Death Kornblum (J Forensic Sci 1991): ► ► ► Review of 16 deaths “associated wit the use of the Taser”. All subjects were drug users. The responding officers believed the subjects were under the influence of PCP (disturbed behavior). 54 Taser Taser and and In-Custody In-Custody Death Death Kornblum (J Forensic Sci 1991): Cause of death: ► Overdose of drugs (cocaine, PCP, amphetamine) 11 cases ► Gunshot wounds - 3 cases ► Heart disease and Taser shock - 1 case ► Undetermined - 1 case “The conclusion reached after evaluation of these cases is that the Taser in and of itself does not cause death, although it may have contributed to death in one case.” 55 In-Custody In-Custody Death Death Prevention Prevention 56 Subjects Subjects at at Risk Risk ► ► ► Obese Elderly Prior medical condition Sickle cell trait Asthma Diabetes Cardiac diseases ► Intoxication Ed Nowicki: 60% of subjects resisting arrest are under the influence of alcohol or drugs (probably underestimated). 57 In-Custody In-Custody Death Death Prevention Prevention Guidelines Guidelines Training: ► ► Be aware of excited delirium and other deadly medical problems. Know when to call EMS and do not hesitate to do it. Medical training: ► ► ► ► CPR and first aid -- Mandatory! Police AED (automated external defibrillator) program First responder certification (40 hours) Additional training for jail personnel? 58 In-Custody In-Custody Death Death Prevention Prevention Guidelines Guidelines Restraints: ► Probably better to avoid the hog-tie position ► Have other types of restraints available ► Do not compress the chest ► Sit the subject as soon as possible, if level of consciousness is normal 59 In-Custody In-Custody Death Death Prevention Prevention Guidelines Guidelines Excited delirium: ► ► Extreme agitation Naked subject IACP criteria (Granfield, International Association of Chiefs of Police 1994): ► ► ► ► ► ► ► Bizarre and/or aggressive behavior Shouting Paranoia Panic Violence towards others Unexpected physical strength Sudden tranquility 60 In-Custody In-Custody Death Death Prevention Prevention Guidelines Guidelines When to call EMS: ► Signs of distress (loss of consciousness, difficulty to breathe, chest pain...) ► Unusual agitation (excited delirium) 61 In-Custody In-Custody Death Death Prevention Prevention Guidelines Guidelines Transport the subject to the hospital: ► Disturbed behavior ► Intoxication ► If the subject requests it ► According to a written procedure (use of nonlethal rounds, LVNR, OC) ► Medical clearance for every arrest? Transportation by EMS preferred (depending on local constraints) 62 In-Custody In-Custody Death Death Prevention Prevention Guidelines Guidelines Documentation: ► Level of consciousness (AVPU scale) ► Subject on medication? ► Orientation ► Quality of speech ... 63 In-Custody In-Custody Death Death Prevention Prevention Speech is perhaps the most sensitive indicator in differentiating between organic and psychiatric disease. Patients with an organic alteration of mental status generally have globally slowed speech patterns. There are often problems with articulation, particularly in toxicmetabolic encephalopathies. Speech that is rapid, well articulated, and well enunciated indicates that the vast majority of the nervous system is functioning normally. Even patients with severe psychiatric disorders often speak rapidly, clearly, and without any obvious hesitation. (G. Henry, in Harwood-Nuss: The Clinical Practice of Emergency Medicine, 1997) 64 In-Custody In-Custody Death Death Prevention Prevention Segest (J Forensic Sci 1987): Review of 19 deaths in police custody in Denmark Most frequent causes of death: Alcohol intoxication Drug poisoning Intracranial hemorrhage “A physician had been consulted but had not diagnosed the seriousness of the condition in 42% of the deaths.” 65