Journal of forensic and legal medicine
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The term Excited Delirium Syndrome (ExDS) has traditionally been used in the forensic literature to describe findings in a subgroup of patients with delirium who suffered lethal consequences from their untreated severe agitation.(1-5) Excited delirium syndrome, also known as agitated delirium, is generally defined as altered mental status and combativeness or aggressiveness. Although the exact signs and symptoms are difficult to define precisely, clinical findings often include many of the following: tolerance to significant pain, rapid breathing, sweating, severe agitation, elevated temperature, delirium, non-compliance or poor awareness to direction from police or medical personnel, lack of fatiguing, unusual or superhuman strength, and inappropriate clothing for the current environment. It has become increasingly recognized that individuals displaying ExDS are at high risk for sudden death, and ExDS therefore represents a true medical emergency. ⋯ For example, agitation, combativeness, and altered mental status can be produced by hypoglycemia, thyroid storm, certain kinds of seizures, and these conditions can be difficult to distinguish from those produced by cocaine or methamphetamine intoxication.(7) Prehospital personnel are generally not expected to differentiate between the multiple possible causes of the patient's presentation, but rather simply to recognize that the patient has a medical emergency and initiate appropriate stabilizing treatment. ExDS patients will generally require transfer to an emergency department (ED) for further management, evaluation, and definitive care. In this paper, we present a typical ExDS case and then review existing literature for current treatment options.
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The safety of placing suspects in the prone position following police use of force has been debated extensively, particularly in the context of sudden in-custody death. The proportion of individuals who remain in the prone position following police use of force is not known, nor has the epidemiology of sudden in-custody death in any position after police restraint been documented. Using a consecutive cohort of individuals in whom police used force, we prospectively documented the number of individuals who were placed in a prone versus not-prone position, and the prevalence of sudden in-custody death in either position. ⋯ One subject died in a not-prone position, no subjects died in the prone position. The sudden in-custody death rate following police use of force was low overall (0.08%, 95% confidence interval (CI) = 0.002, 0.44) and the difference in the proportion of subjects who died suddenly in either position was not significant at 0.14%, (95%CI = -0.8, 0.9). Our results indicate that prone positioning was common and was not associated with death in our cohort of consecutive subjects following police use of force.
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Recently, the National Institute of Justice (NIJ) of the United States of America convened a meeting of experts in the area of Excited Delirium Syndrome (ExDS). The history of ExDS, the clinical presentation, the pathophysiology, differential diagnoses and management options were discussed. ⋯ It is important for law enforcement, medical and other healthcare professionals to be familiar with current knowledge about the syndrome. This paper summarizes the current state and knowledge of ExDS.
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Blunt traumatic cardiac rupture is a relatively uncommon diagnosis and is usually associated with a high mortality rate. A case of delayed cardiac rupture is described in an elderly person who sustained blunt chest trauma following a fall into a roadside ditch. ⋯ Acute cardiac tamponade resulting from rupture of the right ventricle is a serious and life threatening state. A high index of suspicion about the possibility of delayed cardiac rupture is required during the management of a case of polytrauma where significant cardiac findings can be masked by the presence of other injuries.