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