Fatal thromboembolic disease: A risk in physically restrained psychiatric patients

Objective: Physical restraint is used in circumstances where patients exhibit behavior deemed threatening to their health and/or those around them. This practice has been associated with morbidity and mortality in the context of police custody, hospitals and long-term care facilities. While most of these events relate to short-term immobilization, the risks associated with prolonged physical restraint of psychiatric patients are largely unknown. Method: A retrospective review was performed at the Provincial Forensic Pathology Unit for cases of death occurring in physically restrained psychiatric patients. Result: We identified three patients who were immobilized by 4 point, 3-to-5 point and waist physical restraints. The immobilization periods ranged from 3 to 5 days. On autopsy, occlusive pulmonary thromboemboli were identified in each patient. None of the patients had previously recognized coagulopathies or significant risk factors for deep vein thrombosis. Postmortem genetic studies for Factor V and prothrombin mutations were negative. Discussion: Deep vein thrombosis is likely an under recognized occurrence in physically restrained patients under psychiatric care. We propose that deep vein thrombosis and pulmonary embolism be recognized as a risk factor for prolonged physical restraint. As a result, prospective studies examining the incidence and prevention of this adverse outcome is indicated. (C) 2008 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.