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restraint struggles cocaine and sudden death
Title: Unexpected death related to restraint for excited delirium: A
retrospective study of deaths in police custody and in the community.
Subject(s): DEATH -- Causes; DELIRIUM
Source: CMAJ: Canadian Medical Association Journal, 06/16/98, Vol. 158
Issue 12, p1603, 5p, 3 charts
Author(s): Pollanen, Michael S.; Chiasson, David A.; et al
Abstract: Examines the records of 21 cases of unexpected death in
people with excited delirium by the Office of the Chief Coroner for
Ontario between 1988 and 1995. Details on eyewitness testimony,
findings during postmortem examinations, clinical history; Details on
the events surrounding the deaths; The issue of excited delirium and
cocaine use.
AN: 744074
ISSN: 0820-3946
Database: Biomedical Reference Collection: Comprehensive
Section: Evidence
UNEXPECTED DEATH RELATED TO RESTRAINT FOR EXCITED DELIRIUM: A
RETROSPECTIVE STUDY OF DEATHS IN POLICE CUSTODY AND IN THE COMMUNITY
This article has been peer reviewed.
Abstract
Background: Some people in states of excited delirium die while in
police custody. Emerging evidence suggests that physical restraint in
certain positions may contribute to such deaths. In this study the
authors determined the frequency of physical restraint among people in
a state of excited delirium who died unexpectedly.
Methods: The authors reviewed the records of 21 cases of unexpected
death in people with excited delirium, which were investigated by the
Office of the Chief Coroner for Ontario between 1988 and 1995.
Eyewitness testimony, findings during postmortem examinations,
clinical history, toxicological data and other official documents
describing the events surrounding the deaths were analysed. Specific
reference was made to documented eyewitness testimony of restraint
method, body position and use of capsicum oleoresin (pepper) spray.
Because cocaine was detected in the blood of some of these people
during the postmortem examination, the role of cocaine in excited
delirium was examined by comparing the cocaine levels in these cases
with levels in 2 control groups: 19 people who died from acute cocaine
intoxication and 21 people who had used cocaine shortly before they
died but who had died from other causes.
Results: In all 21 cases of unexpected death associated with excited
delirium, the deaths were associated with restraint (for violent
agitation and hyperactivity), with the person either in a prone
position (18 people [86%]) or subjected to pressure on the neck (3
[14%]). All of those who died had suddenly lapsed into tranquillity

shortly after being restrained. The excited delirium was caused by a
psychiatric disorder in 12 people (57%) and by cocaine-induced
psychosis in 8 (38%). Eighteen people (86%) were in police custody
when they died. Four (19%) had been sprayed with capsicum oleoresin,
and heart disease was found in another 4 at autopsy. The blood level
of cocaine in those whose excited delirium was cocaine induced was
similar to levels found in recreational cocaine users and lower than
levels found in people who died from cocaine intoxication.
Interpretation: Restraint may contribute to the death of people in
states of excited delirium, and further studies to test this
hypothesis are recommended. Meanwhile, law enforcement authorities and
others should bear in mind the potential for the unexpected death of
people in states of excited delirium who are restrained in the prone
position or with a neck hold.
Observations over the last 15 years have led forensic experts to
recognize a new syndrome of unexpected death that may be preventable.
The syndrome was first observed in 1982 when investigators in Seattle
described the sudden death of people in states of acute psychiatric
agitation and hyperactivity who were being restrained by law
enforcement officers using neck holds.1 It has since become apparent
that some acutely excited, agitated and violent people, in states of
so-called "excited delirium," are at risk of dying unexpectedly when
restrained (e.g., by law enforcement officers or hospital
personnel).1-3 Positional or postural holds are the restraints most
frequently associated with unexpected death in susceptible people with
excited delirium. These holds are used to subdue; those being
restrained are positioned prone on the floor with their wrists or
ankles bound (e.g., with handcuffs). The most extreme example of
prone-position restraint is "hog-tying," in which the person is
positioned prone with ankles and wrists bound together at the back of
the torso.2 The concept of "positional asphyxia" due to restraint
arose when it was recognized that being in the prone position could
severely restrict breathing and compromise cardiac function in an
agitated person.3,4 Other variants of positional asphyxia are well
recognized and include restrictive positioning of the body in severely
intoxicated people who become unconscious.5
Important elements in death from positional asphyxia include the
proximate cause of the excited delirium and risk factors that may
predispose a person to unexpected death. Initial studies1-3 focused on
acute psychiatric illness, but cocaine-induced psychosis has also been
implicated. In addition, other types of incapacitation, including the
use of the lacrimatory agent capsicum oleoresin spray (commonly known
as pepper spray), have been associated with the unexpected death of
people with excited delirium, particularly people with heart disease.6
In this study we examined the frequency of positional or postural
restraint in cases of unexpected death of people with excited
delirium. The role of cocaine in some of these deaths was also
examined with reference to appropriate control groups. The potential
association of excited delirium and positional asphyxia with
unexpected death has special implications for physicians who may
encounter people in such situations.
Methods

Selection of cases
We examined the records from the Office of the Chief Coroner for
Ontario for cases of unexpected death associated with excited delirium
that occurred between 1988 and 1995; there were 21 such cases. The
retrospective diagnosis of excited delirium was made by examining
official documents describing the events immediately before the deaths
and, in many cases, eyewitness accounts describing the person's
behaviour in the hours before death. All 21 people exhibited
well-described characteristics of excited delirium,2,7,8 including
bizarre or hyperactive behaviour, paranoia, shouting, thrashing,
ranting and performing feats of apparently "superhuman" strength.
Eyewitness accounts indicated that the people were in a variety of
situations and circumstances when they became agitated, ranging from
causing disturbances in public places to behaving bizarrely (e.g.,
swinging from electrical power cables and attacking streetcars) to
resisting arrest. The documents were studied to determine whether
those who died had been restrained, their position at the time of
death, whether they were in police custody, whether pepper spray had
been used and whether they had a history of drug abuse or psychiatric
illness. In all 21 cases, full external and internal postmortem
examinations had been performed, along with comprehensive
toxicological analyses of cardiac blood collected after death; these
findings were also examined.
Postmortem analysis of blood levels of cocaine
The excited delirium was thought to be cocaine induced in 8 (38%) of
the 21 cases. Postmortem blood levels of cocaine and benzoylecgonine
(a metabolite of cocaine) were available for 6 of these; the other 2
had survived for a short time in hospital, which rendered postmortem
cocaine levels less meaningful. To assess the relevance of these
findings, we compared them with postmortem blood levels of cocaine in
2 control groups, one consisting of 19 people who had died of either
intentional or accidental cocaine intoxication and the other
consisting of 21 people who either were murdered or committed suicide
by means other than cocaine intoxication but who had used cocaine
shortly before death.
Results
Of the 21 people in whom unexpected death was associated with excited
delirium, 20 (95%) were men. The mean age was 33 years (Table 1). All
of the deaths were associated with restraint, either in the prone
position (18 people [86%]) or with pressure applied to the neck (3
people [14%]; Table 2). Eight (44%) of the 18 people who were
restrained in the prone position also suffered chest compression from
the body weight of the 1 to 5 people restraining them. All 21 people
had suddenly lapsed into tranquillity shortly after being restrained
(for violent agitation and hyperactivity). In 12 cases (57%) the
excited delirium resulted from a psychiatric disorder, and in 8 (38%)
it was the result of cocaine-induced psychosis. Eighteen of the deaths
(86%) occurred while the people were in police custody. Pepper spray
had been used in 4 cases (19%). During autopsy, hypertensive or
atherosclerotic heart disease was found in 4 people (19%), but there
were no cases of life-threatening injury. Nineteen people (90%) died

at the time of restraint and could not be resuscitated; 2 people (10%)
were resuscitated but remained in a deep coma in hospital for several
days before they died; in these cases the excited delirium was related
to cocaine intoxication. In 5 people petechial hemorrhage was seen
during the postmortem examination, but only 2 of these had
conjunctival petechiae; both had suffered neck compression. In the
other 3 people, subpleural and epicardial petechiae were seen; one of
these had suffered neck compression and the others had been restrained
in the prone position.
Excited delirium and cocaine use
The mean cocaine level in the 6 people with cocaine-induced excited
delirium in this study was similar to that of recreational users but
much lower than that of people who died of cocaine intoxication (Table
3). The blood level of benzoylecgonine in people with cocaine-induced
excited delirium fell between the levels for recreational users and
those who died of cocaine intoxication (Table 3).
Interpretation
The most striking finding of this study was that all of those who died
unexpectedly during or after an episode of excited delirium had been
physically restrained. In most cases the excited delirium was due to a
pre-existing psychiatric illness; however, in a significant number, it
was a consequence of recent cocaine use. In the latter cases, the
cocaine levels were similar to those found in people who were murdered
or had committed suicide and had used cocaine shortly before death
(i.e., cocaine was not a cause of death). This suggests that the
levels of cocaine associated with recreational use may be sufficient
to cause excited delirium. The blood level of benzoylecgonine was
higher in people with cocaine-induced excited delirium than in
recreational users. Because the elimination half-life of
benzoylecgonine is much longer than that of the parent compound,
cocaine, this finding is consistent with a recent cocaine "binge."
To adequately investigate and ultimately prevent these deaths, the
association between cocaine-induced excited delirium and physical
restraint must be recognized. In a recent study7 from Dade County,
Fla., of sudden death related to cocaine-induced excited delirium, the
blood levels of cocaine and benzoylecgonine were similar to those
reported here. In addition, the investigators found that police
custody was the most important factor determining sudden death of
people with excited delirium; those affected were usually restrained.
Despite this finding, the investigators concluded that restraint or
positional asphyxia was not a factor in the deaths. Similarly, another
study described 7 people with cocaine-related excited delirium, all of
whom died while being restrained;8 the cocaine levels in these people
were similar to the levels observed in our study. Again, restraint was
not considered a factor in the deaths; the researchers postulated that
cardiac arrhythmias from the excited delirium were the cause.
Nevertheless, the possibility that positional asphyxia contributes to
unexpected death in people in states of excited delirium cannot be
ignored.
Other factors may contribute to restraint-related death in people with
excited delirium: pre-existing heart disease, obesity (particularly in

those with a large abdominal pannus) leading to restricted ventilation
in the prone position, and exposure to pepper spray. Exposure to
pepper spray was associated with sudden death in 2 people with excited
delirium who had underlying cardiac or pulmonary disease.6 In our
study the hypertensive or atherosclerotic heart disease found in some
people might have predisposed them to unexpected death. As well, a few
people were exposed to pepper spray.
Our findings indicate that many deaths related to excited delirium are
associated with restraint in the prone position. Acute excited
delirium resulting from psychiatric illness or cocaine use was the
most important underlying cause. It may be that the greater oxygen
requirement of people with excited delirium predisposes them to rapid
anoxic death if they are restrained. Because our study was
retrospective and did not include controls, we could not establish a
definitive causal link between unexpected death and restraint in
people with excited delirium. However, an anoxic mechanism is
biologically plausible, and the results of our study combined with
those previously reported suggest that the hypothesis of
restraint-related asphyxia associated with excited delirium needs
careful consideration. We suggest further study to determine whether
the unexpected death of people with excited delirium may be due, in
part, to restraint practices.
References
1.Reay DT, Eisele JW. Death from law enforcement neck holds. Am J
Forensic Med Pathol 1982;3(3):253-8.
2.O'Halloran RL, Lewman LV. Restraint asphyxiation in excited
delirium. Am J Forensic Med Pathol 1993;14(4):289-95.
3.Reay DT, Fligner CL, Stilwell AD, Arnold J. Positional asphyxia
during law enforcement transport. Am J Forensic Med Pathol
1992;13(2):90-7.
4.Reay DT, Howard JD, Fligner CL, Ward RJ. Effect of positional
restraint on saturation and heart rate following exercise. Am J
Forensic Med Pathol 1988;9(1):16-8.
5.Bell MD, Rao VJ, Wetli CV, Rodriguez RN. Positional asphyxiation in
adults: a series of 30 cases from the Dade and Broward County Florida
Medical Examiners Offices from 1982 to 1990. Am J Forensic Med Pathol
1992;13(2):101-7.
6.Steffee CH, Lantz PE, Flannagan LM, Thompson RL, Jason DR. Oleoresin
capsicum (pepper) spray and in-custody deaths. Am J Forensic Med
Pathol 1995;16(3):185-92.
7.Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC.
Fatal excited delirium following cocaine use: epidemiologic findings
provide new evidence for mechanisms of cocaine toxicity. J Forensic
Sci 1997;42(1):25-31.
8.Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in
recreational cocaine users. J Forensic Sci 1985;30(3):873-80.

Reprint requests to: Dr. Michael S. Pollanen, Forensic Pathology Unit,
Office of the Chief Coroner for Ontario, 26 Grenville St., Toronto ON
M7A 2G9; fax416314-4060
Table 1: Characteristics Of 21 People With Excited Delirium Who Died
Unexpectedly After Being Restrained (Ontario, 1988-1995)
KEY
A
B
C
D

=
=
=
=

Sex; no. Men
Sex; no. Women
Mean age, yr (and SD)
Circumstances surrounding death; no. (and %);
In police custody*
E = Circumstances surrounding death; no. (and %);
Subdued with pepper spray
F = Circumstances surrounding death; no. (and %);
Had heart disease**
Cause of excited
delirium

A

B

Psychiatric illness@

12

0

35 (11)

Cocaine-induced
psychosis

7

1

31 (7)

7 (88)

0

2 (25)

Toxic effects of
other drugs@@

1

0

17

1 (100)

0

0

20

1

33 (10)

Total

C

D

E

10 (83) 4 (33)

18 (86) 4 (19)

F
2 (17)

4 (19)

Note: SD = standard deviation.
*Either in prison or while under arrest.
**Hypertensive or atherosclerotic heart disease.
@Includes one person with multiple drug intoxication (pseudoephedrine
and dextramethorphan) and another with a history of cocaine use but no
evidence of cocaine use just before death.
@@Combined effects of alcohol, morphine, diazepam, acetaminophen and
marijuana.
Table 2: Methods Used To Restrain The 21 People
Method of restraint

No. (and %) of people

Prone
With chest compression
With handcuffs
With handcuffs and ankle shackles*
With chest compression, handcuffs
and ankle shackles
Pressure applied to neck

4
4
6

(19)
(19)
(29)

4
3

(19)
(14)

*Includes 2 people who were "hog-tied."
Table 3: Postmortem Blood Levels Of Cocaine And Benzoylecgonine In
People With Cocaine-Induced Excited Delirium And 2 Control Groups
Compound; mean blood level
(and SD), mg/dL
Group

No.

Cocaine

Benzoylecgonine

Cocaine-induced psychosis*

6

0.04 (0.03)

0.50 (0.50)

Recreational cocaine use@

21

0.04 (0.04)

0.24 (0.16)

Cocaine intoxication@@

19

0.97 (1.60)

1.70 (1.30)

*People who died suddenly in a state of cocaine-induced excited
delirium (this study).
@People who either were murdered or committed suicide by means other
than cocaine intoxication but who had used cocaine shortly before
death (source: data from Office of the Chief Coroner for Ontario).
@@People who died of either intentional or accidental cocaine
intoxication (source: data from Office of the Chief Coroner for
Ontario).
ILLUSTRATION
~~~~~~~~
By Michael S. Pollanen, PhD; David A. Chiasson, MD; James T. Cairns,
MD; James G. Young, MD
Dr. Pollanen is Adjunct Professor of Forensic Sciences and a medical
student at the University of Toronto and Consultant, Office of the
Chief Coroner for Ontario, Toronto, Ont.; Dr. Chiasson is Chief
Forensic Pathologist for Ontario, Dr. Cairns is Deputy Chief Coroner
for Ontario, and Dr. Young is Chief Coroner for Ontario, Office of the
Chief Coroner for Ontario, Toronto, Ont. This email was generated by a
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