Authors :
Ryan Budde, PhD – Seattle Children's Hospital
Laura Gould, MSc – New York University Grossman School of Medicine
Orrin Devinsky, MD – NYU Comprehensive Epilepsy Center, NYU Langone Medical Center
Presenting Author: Jan-Marino Ramirez, PhD – Seattle Children's Hospital
Rationale:
In March 2024 the Associated Press (AP) published data on 1,036 individuals who died shortly after first responder restraint from 2012–2021. The AP did not have time to investigate every case in detail and so published limited data on most cases. They reported a handful of cases in greater detail. One detailed case described an individual with epilepsy who experienced a seizure and 911 was called. His postictal confusion, aversion to touch, and inability to follow instructions led to the use of restraint by first responders. He was tased and handcuffed prone with a bag over his head. Shortly after, his breathing ceased, and he could not be resuscitated. We reviewed the AP database to identify similar seizure-related deaths.Methods:
We obtained original documents from 43 cases in the AP database which were identified with the keywords “epilepsy” or “seizure”. We independently obtained records for 3 additional cases. Records include police reports, body camera footage, autopsy reports, and similar documents either obtained by the AP or obtained on our own through online public sources. We exclude 7 records for lack of credible seizure or epilepsy. We reviewed 39 cases when a seizure occurred shortly before first responder restraint and death, and/or an individual with a seizure history died after first responder restraint. Results:
Group 1: 19/39 cases were associated with seizure during a likely overdose, and the seizure was probably drug induced. In 18 of these cases agitation began before the seizure. Group 2: In 13/39 cases an individual had a seizure, 911 was called, and the individual was restrained and later became unresponsive at the scene and could not be resuscitated. In these cases, there is no cause of death identified beyond seizure and restraint. Postictal agitation, mania, aversion to touch, confusion, or inability to follow instructions was documented in 12/13 cases; postictal behavior appeared to provoke first responder restraint. Only 2/13 cases were associated with unprovoked postictal violence. None of the 13 cases were agitated before the seizure. Group 3: 7/39 cases displayed complex, multifactorial phenotypes.
Conclusions:
Agitation, mania, drug overdose, and seizure are common phenotypes that first responders must handle, accounting for 5-10% of the 40 million annual EMS calls in the US [1-3]. Our data suggest postictal agitation may increase the risk for seizure-related mortality associated with first responder interventions to subdue patients. Preictal agitation strongly suggests the seizure was drug induced, while postictal agitation was more likely seizure related. While postictal restraint and rapid transport is sometimes indicated, greater education to first responders to slow down and avoid provocative interactions may allow postictal mania to subside before the risks of restraint are necessary.
References:
[1] Rivard et al. 2022. Prehosp Emerg Care.
[2] Michael et al. 2011. Emerg Med Clinics.
[3] Mell et al. 2017. JAMA Surg.
Funding:
R01HL126523
R01HL144801
F32NS143860
Finding A Cure for Epilepsy and Seizures (FACES)