Doctor Meng AwYong works in Emergency Medicine, in pre-hospital care, as a forensic medical examiner for the Metropolitan Police and has co-authored the Royal College of Emergency Medicine Best Practice Guidance on the Management of ABD. Here, he outlines what is thought to be the most dangerous condition to affect detainees: ABD.

What is ABD?

ABD sounds like a new-fangled neuro- psychoactive drug (NPS). Well it’s not, it used to be called excited delirium but is now called acute behavioural disturbance.

It is not a medical condition but describes someone presenting with some or all of the following: agitation, high temperature (hot to touch, sweating, undressing), super strength, paranoia (fear of people, things dying).

What causes ABD?

There will usually be a history of stimulant drugs abuse e.g. cocaine, and many will be suffering from a mental health illness. There are some medical causes such as brain tumours, high thyroxine levels and low blood sugar.

Is it dangerous?

Their agitation, strength and paranoia can be frightening. The current
theory is the stimulant drug triggers the agitation, this combined with increased activity will cause an increase of their metabolism. This in turns causes changes in the body such as

an increased acid state and a rise in potassium. Further restraint (activity) exacerbates this and at a certain point sudden cardiac arrest can occur.

How should ABD be managed?

Slowing down the metabolism i.e. avoiding or keeping restraint to a minimum. De-escalation techniques such as speaking to them, containment (closing cell doors) should be tried first. Failing that, or if the agitation is severe, the Ambulance Service should be called.

Calling for emergency services

The 999 operators must be told the following information: the person has Acute Behavioural Disturbance, it’s a medical emergency and they are likely to go into cardiac arrest. Describe what you see to the 999 operators. Always check with the ambulance operator

what category they have allocated to this call. If the ambulance operator is unaware of what ABD is and has not assessed this call as an emergency Red 1 call, then you must escalate this to a senior person.

What is the medical treatment for ABD?
Try and avoid restraint – this can tip the person over the edge. If this is unavoidable then ensure they are sitting up if possible, avoid a face- down position or any pressure on
their abdomen or chest, and ensure
the restraints are not too tight to allow some free movement. If available, apply oxygen and have the defibrillator ready.

Chemical sedation using medication will reduce the exertion, strain on heart and allow control of breathing. Some ambulances have critical care paramedics who can sedate and they are usually on the air ambulance. It is therefore crucial that your police force or prison service have a memorandum of understanding (MOU) with your ambulance trust on responding to ABD cases as a Red 1 call and respond with the ability to chemically sedate.

What has gone wrong before and how how this led to deaths?
Some contributing factors have been: excessively long restraint, compromised airway/breathing positions, delay in recognising ABD and that it is a medical emergency, delay calling for an ambulance. Lack of understanding amongst police officers, police control room operators, ambulance operators and ambulance staff has also meant that ABD is sometimes not treated as
a medical emergency. The failure of ambulance trusts to add ABD outside of the usual triage call pathways and respond with chemical sedation can be another important factor.

For more information on ABD, see the Best Practice Guideline document at www.rcem.ac.uk.