Deaths during apprehensions of agitated persons. A review of proposed pathophysiological theories

Abstract

The pathophysiology of sudden death during apprehension remains largely unclear. The most frequently discussed mechanisms are excited delirium, positional asphyxia, metabolic acidosis, acute and chronic drug abuse, and autonomic instability. As in most areas of forensic medicine, much of the knowledge comes from case reports, which are of little use in understanding causality. Experimental studies of some aspects have been performed, and they show somewhat divergent results and interpretations. The aim of this review is to summarize the different proposed theories, and to point out important issues for further research.

The NICE 10 minute physical restraint rule: A discussion of the relative risks

“…As a result of this, there is an accumulation of hydrogen ions which would otherwise be processed via the electron transport chain to produce urgently required needed ATP (Burton et al., ). This build‐up of hydrogen ions causes the pH level in the muscles to decrease, giving rise to a state of metabolic acidosis (Tamsen & Thiblin, ). This can result in the muscles losing their ability to contract effectively, resulting in muscle force production and the ability to sustain the current level of effort declining over time (McLester, ).…”

“…Rather, the fatal outcome is determined by a combination of the prevailing health status of the individual being restrained, the physiological changes caused by the subjective experience of restraint along with the resulting resistance to it, as well as the nature and degree of force employed by staff (Duxbury, Aiken, & Dale, ). The research base around our understanding of these risk factors and their interplay continues to grow despite real‐world fidelity within experiments often remaining ethically out of reach (Paterson et al., ; Tamsen & Thiblin, ). It is reasonable however to conclude that the longer a restraint episode goes on, the more dangerous it can become for the individual being restrained.…”