CorrectCare

Acute Psychotic Delirium and Sudden Death in Custody:
Tips for Prevention

by Holly Mathis, MSN, RN, ANP-BC

Without warning, a detainee changes from a tabby cat to Tyrannosaurus rex. There’s a good chance that the cause is acute psychotic delirium, which is associated with numerous therapeutic and recreational drugs. Given the increase in the use and abuse of drugs that have psychogenic side effects, it is vitally important that correctional staff and health care professionals recognize APD, understand the factors related to managing it and be prepared and trained to manage its occurrence as a team.

First, what is acute psychotic delirium? APD is an abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness and/or the sleep/wake cycle that develops over a short period of time. It reflects a significant change from previous functioning and can affect attention, concentration, speech, memory and perception.

Drugs of abuse commonly associated with APD include cocaine, alcohol and PCP. Additionally, abusers of cocaine, methamphetamine and alcohol are at increased cardiac risk because of the physiologic action of these drugs on the heart. But drugs aren’t the only culprit. Conditions that may cause an altered level of consciousness or delirium are summarized by the well-known mnemonic “AEIOU TIPS”:

A = Acidosis
E = Epilepsy (seizures or convulsions)
I = Infection
O = Overdose drugs or alcohol
U = Uremia
T = Trauma to head; tumor
I = Insulin (high or low blood sugar)
P = Poisoning psychosis
S = Stroke (transient ischemic attack or cerebrovascular accident)

APD is considered a serious medical emergency. Individuals in this state display extraordinary strength and endurance when struggling, apparently without fatigue. A correctional officer may see bizarre and alarming behavior and perceive it as strictly a control-and-arrest or contain situation. The individual may be partially clothed or naked, incoherent or speaking in gibberish, yelling or screaming. APD victims are disoriented or hallucinating and may even be foaming at the mouth or drooling. There is profuse sweating or body temperature may be elevated yet uncooled despite significant perspiration. The typical patient is a male in his early 30s. Interestingly, the incidence of APD increases as the end of the week approaches.

Significant Risk
The patient experiencing APD is at significant risk for sudden death in custody related to positional asphyxia because of the method all too often employed when restraining the individual. Restraint asphyxia is a form of positional asphyxia that occurs during the process of subduing and restraining an individual in a manner that causes ventilatory compromise. Before or during restraint, the patient may struggle or attempt to flee, increasing respiratory requirements. Metabolic acidosis may develop as lactic acid builds up from muscle contractions secondary to attempts to elude containment. Respirations are necessary to resolve respiratory acidosis, but attempts at restraint serve to impair ventilatory capabilities because of the techniques used to subdue the individual.

Death related to positional asphyxia is a particular risk not only for those experiencing a prolonged struggle prior to restraint, but also for the obese and those with significant respiratory and cardiac medical history.

Obesity itself results in decreased lung capacity (restriction) and is related to sleep apnea. Known in extreme circumstances as obesity hypoventilation syndrome, or the Pickwickian syndrome, after the Charles Dickens character in “The Pickwick Papers,” this condition causes difficulty with chest excursion because the body’s excessive weight creates pressure against the diaphragm, particularly when supine but exacerbated when prone. The prone position reduces lung capacity in nonobese individuals, as well. During restraint, the situation may be compounded by pressure exerted by the restraining officer.

Patients with a medical history significant for respiratory or cardiac complaints are also at risk. Respiratory history may include asthma, chronic obstructive pulmonary disease (often tobacco-related), interstitial lung disease, sarcoidosis or cystic fibrosis. A cardiac history significant for conditions such as arrhythmias, cardiomegaly or hypertrophic cardiomyopathy also places patients at risk for sudden death related to positional restraints.

The policy of placing combative patients in a prone position after restraint is still all too common. The procedure known as hog-tying is well known in corrections, but thankfully, is beginning to decline in use. Juveniles are often restrained by adults lying or sitting on them. It is important to differentiate prone containment (the brief physical holding of an individual prone, usually on the floor, for the purpose of effectively gaining quick control of an aggressive and agitated individual) from prone restraint (extended restraint, either physical or mechanical).

Any of these forms of restraint may lead to asphyxia, but positional asphyxia is the term used when a patient is left in this position for an extended period after restraint, or the body is positioned in a way that interferes with the ability to breathe, resulting in insufficient intake of oxygen that leads to death. Death attributable to positional asphyxia can be considered a homicide.

Steps for Prevention
There are steps that can be taken to reduce death from positional asphyxia. Most importantly, avoid obstructing the airway. Next, make it a policy to avoid hog-ties completely. It is preferable to apply restraints to extremities separately, avoiding pressure to chest, back, lungs, diaphragm or stomach in order to allow respiration, particularly as soon as the individual has been safely restrained. Avoid sitting or lying on the individual, particularly juveniles. Right after restraint, move the position from stomach to side-lying or sitting (if alert). Don’t allow the person to sit leaning or “slumped” forward. Do not leave a person who struggled before and during restraint efforts unattended!

Always assign an observer to note the situation from the beginning of the restraint process, to monitor the patient for any breathing problems or, more ominously, loss of consciousness. Loss of consciousness after a challenging restraint often leads to death in conjunction with APD and requires quick intervention, including CPR and immediate transport to an emergency room.

The key to success is advance training. The “Four Rs” summarize the steps necessary to successful management of this situation:

• Recognize the situation for what it is
• Respond appropriately
• Restrain quickly
• Refer immediately

Recognizing the situation is easy: Once you see it, you will not easily forget. Awareness of the situation and the potential for it will put you at a distinct advantage.

Responding appropriately is critical. It is vital to avoid obstructing airway and breathing capabilities during and after containment. It is important to restrain the patient quickly, avoiding hog ties and extended prone containment. Make sure that there are enough people to contain the patient at the outset in order to prevent a prolonged struggle.

Restraining quickly requires advance planning and practice. A “TARP” plan, or total appendage restraint procedure, may facilitate these efforts. Consider developing a coordinated plan in advance in collaboration with site personnel, including medical providers, plus the local emergency medical services and local hospital emergency department personnel. Training officers and EMS dispatchers ahead of time to recognize the urgency of the situation will improve the chances of a favorable outcome.

— About the author: Holly Mathis, MSN, RN, ANP-BC, is a nurse practitioner employed by Correctional Medical Services and working in the Arkansas Department of Correction.

[This article first appeared in the Fall 2010 issue of CorrectCare.]