{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T04:51:04Z","timestamp":1791607864401,"version":"4.3.4"},"reference-count":85,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2025,11,25]],"date-time":"2025-11-25T00:00:00Z","timestamp":1764028800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2025,11,25]],"date-time":"2025-11-25T00:00:00Z","timestamp":1764028800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100011681","name":"R\u00e4ttsmedicinalverket","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100011681","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Forensic Sciences"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    Restraint\u2010related sudden deaths in agitated individuals raise complex questions at the intersection of medicine and law. Hyperactive delirium with extreme agitation as well as positional asphyxia due to restraint have been proposed to account for these deaths. However, the exact physiological mechanisms responsible and to what extent restraint contributes to the lethal outcome remain debated. In this nationwide, 32\u2010year retrospective study between 1992 and 2024, we examined circumstances surrounding sudden deaths during restraint of agitated individuals in Sweden. A total of 52 cases were identified, with an average of 0.17 deaths per million inhabitants annually. Ninety percent of cases involved prone restraint and 69% showed evidence of stimulant use. In 15 cases from 2005 onward, peri\u2010arrest arterial blood gas data revealed profound metabolic and respiratory acidosis, with a mean blood pH of 6.52 (range: 6.30\u20136.95; median: 6.50), mean lactate concentration of 26.3\u2009mmol\/L (range: 8.6\u201341.0; median: 30), and mean pCO\n                    <jats:sub>2<\/jats:sub>\n                    of 14.8\u2009kPa (range: 6.4\u201322.3; median: 15.3). Based on these findings, we propose a two\u2010phase pathophysiological model of restraint\u2010related cardiac arrest. The initial \u201cpriming phase\u201d involves extreme physical exertion, creating a critically acidotic state that requires full respiratory and cardiovascular function to maintain homeostasis. If the \u201cpriming phase\u201d is followed by restraint that restricts ventilatory function and hampers venous return, e.g., restraint in the prone position, an unstable \u201ctipping phase\u201d is initiated, that may culminate in cardiac arrest. This model builds on previous hypotheses and emphasizes the potentially lethal consequences of inhibiting ventilatory function in acutely agitated individuals.\n                  <\/jats:p>","DOI":"10.1111\/1556-4029.70237","type":"journal-article","created":{"date-parts":[[2025,11,26]],"date-time":"2025-11-26T04:55:38Z","timestamp":1764132938000},"page":"821-836","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Incidents of sudden death during restraint of agitated individuals in Sweden between 1992 and 2024"],"prefix":"10.1111","volume":"71","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-8246-092X","authenticated-orcid":false,"given":"Alexander","family":"Tyr","sequence":"first","affiliation":[{"name":"Swedish National Board of Forensic Medicine Stockholm  Solna Sweden"},{"name":"Department of Laboratory Medicine Karolinska Institutet  Huddinge Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-1932-721X","authenticated-orcid":false,"given":"Erik","family":"Lindeman","sequence":"additional","affiliation":[{"name":"Swedish Poisons Information Centre  Solna Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5038-7512","authenticated-orcid":false,"given":"Fredrik","family":"Tamsen","sequence":"additional","affiliation":[{"name":"Swedish National Board of Forensic Medicine Uppsala  Uppsala Sweden"},{"name":"Department of Surgical Sciences Akademiska Sjukhuset, Uppsala University  Uppsala Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2962-2466","authenticated-orcid":false,"given":"Ingemar","family":"Thiblin","sequence":"additional","affiliation":[{"name":"Swedish National Board of Forensic Medicine Uppsala  Uppsala Sweden"},{"name":"Department of Surgical Sciences Akademiska Sjukhuset, Uppsala University  Uppsala Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3837-1195","authenticated-orcid":false,"given":"Brita","family":"Zilg","sequence":"additional","affiliation":[{"name":"Swedish National Board of Forensic Medicine Stockholm  Solna Sweden"},{"name":"Department of Oncology\u2010Pathology Karolinska Institutet  Stockholm Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2025,11,25]]},"reference":[{"key":"e_1_2_10_2_1","volume-title":"D\u00f6dsfall vid polisingripande. Riskfaktorer och rekommendationer: PHS serie i polisi\u00e4rt arbete [sudden death during police restratint. Risks and recommendations: Swedish National Police Academy handbook series on police work]","author":"Thiblin I","year":"2011"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/PAF.0000000000000934"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/NMD.0000000000001637"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12024\u2010020\u201000291\u20108"},{"key":"e_1_2_10_6_1","volume-title":"White paper report on excited delirium syndrome","author":"ACEP Excited Delirium Task Force","year":"2009"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.emc.2023.06.011"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/1556\u20104029.14524"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/1556\u20104029.15101"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1054\/jcfm.1999.0344"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/s0169\u2010328x(99)00233\u20108"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1177\/014107689909200303"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.1520\/JFS11020J"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1093\/eurpub\/ckac105"},{"key":"e_1_2_10_15_1","doi-asserted-by":"publisher","DOI":"10.2147\/ndt.s2883"},{"key":"e_1_2_10_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2011.12.008"},{"key":"e_1_2_10_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2016.03.006"},{"key":"e_1_2_10_18_1","doi-asserted-by":"publisher","DOI":"10.1111\/acem.14483"},{"key":"e_1_2_10_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.shpsa.2023.12.009"},{"key":"e_1_2_10_20_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12024\u2010018\u20100005\u20108"},{"key":"e_1_2_10_21_1","doi-asserted-by":"publisher","DOI":"10.1177\/0025802415579617"},{"key":"e_1_2_10_22_1","doi-asserted-by":"publisher","DOI":"10.2310\/8000.2013.130824"},{"key":"e_1_2_10_23_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2019.06.009"},{"key":"e_1_2_10_24_1","doi-asserted-by":"publisher","DOI":"10.1520\/JFS12748J"},{"key":"e_1_2_10_25_1","doi-asserted-by":"publisher","DOI":"10.1093\/jat\/bkaa018"},{"key":"e_1_2_10_26_1","doi-asserted-by":"publisher","DOI":"10.1520\/JFS14071J"},{"key":"e_1_2_10_27_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00216\u2010013\u20106798\u20100"},{"key":"e_1_2_10_28_1","unstructured":"WilliamsHE.Physiological attributes of arrest\u2010related sudden deaths proximate to the application of taser electronic control devices: an evidence based study of the theory of high risk groups. [Dissertation] San Marcos TX: Texas State University2013."},{"issue":"12","key":"e_1_2_10_29_1","first-page":"1603","article-title":"Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community","volume":"158","author":"Pollanen MS","year":"1998","journal-title":"CMAJ"},{"key":"e_1_2_10_30_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2016.04.010"},{"key":"e_1_2_10_31_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2020.101966"},{"key":"e_1_2_10_32_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2007.10.005"},{"key":"e_1_2_10_33_1","doi-asserted-by":"publisher","DOI":"10.2478\/sjfs\u20102013\u20100006"},{"key":"e_1_2_10_34_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1553\u20102712.1999.tb00164.x"},{"key":"e_1_2_10_35_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2019.06.013"},{"key":"e_1_2_10_36_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12024\u2010022\u201000548\u20104"},{"key":"e_1_2_10_37_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.resuscitation.2016.06.013"},{"key":"e_1_2_10_38_1","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000003960"},{"key":"e_1_2_10_39_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598\u2010021\u201002764\u20104"},{"key":"e_1_2_10_40_1","doi-asserted-by":"publisher","DOI":"10.3906\/sag\u20101812\u2010156"},{"key":"e_1_2_10_41_1","doi-asserted-by":"publisher","DOI":"10.1016\/s0196\u20100644(87)80677\u20107"},{"key":"e_1_2_10_42_1","doi-asserted-by":"publisher","DOI":"10.1186\/cc3714"},{"key":"e_1_2_10_43_1","doi-asserted-by":"publisher","DOI":"10.1016\/s0300\u20109572(00)00162\u20103"},{"key":"e_1_2_10_44_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.resuscitation.2007.10.005"},{"key":"e_1_2_10_45_1","doi-asserted-by":"publisher","DOI":"10.1136\/emj.9.2.169"},{"key":"e_1_2_10_46_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13054\u2010017\u20101893\u20109"},{"key":"e_1_2_10_47_1","doi-asserted-by":"publisher","DOI":"10.1186\/cc9976"},{"key":"e_1_2_10_48_1","doi-asserted-by":"publisher","DOI":"10.21037\/jtd.2019.12.127"},{"key":"e_1_2_10_49_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2022.1025"},{"key":"e_1_2_10_50_1","doi-asserted-by":"publisher","DOI":"10.1177\/0025802420988370"},{"key":"e_1_2_10_51_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp2407162"},{"key":"e_1_2_10_52_1","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.2001.90.5.1798"},{"key":"e_1_2_10_53_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598\u2010021\u201094157\u2010w"},{"key":"e_1_2_10_54_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jemermed.2009.12.002"},{"issue":"4","key":"e_1_2_10_55_1","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1177\/002013240004500405","article-title":"Spirometry in normal subjects in sitting, prone, and supine positions","volume":"45","author":"Vilke GM","year":"2000","journal-title":"Respir Care"},{"key":"e_1_2_10_56_1","doi-asserted-by":"publisher","DOI":"10.1016\/s0736\u20104679(99)00083\u20109"},{"key":"e_1_2_10_57_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2013.08.006"},{"key":"e_1_2_10_58_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2020.101982"},{"issue":"10","key":"e_1_2_10_59_1","first-page":"359","article-title":"Cardiorespiratory consequences to hobble restraint","volume":"109","author":"Roeggla M","year":"1997","journal-title":"Wien Klin Wochenschr"},{"key":"e_1_2_10_60_1","doi-asserted-by":"publisher","DOI":"10.1097\/00000433\u2010198803000\u201000005"},{"key":"e_1_2_10_61_1","doi-asserted-by":"publisher","DOI":"10.1258\/rsmmsl.48.2.137"},{"key":"e_1_2_10_62_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1556\u20104029.2006.00296.x"},{"key":"e_1_2_10_63_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcfm.2004.10.013"},{"key":"e_1_2_10_64_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2007.08.017"},{"key":"e_1_2_10_65_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.paf.0000136639.69128.bc"},{"key":"e_1_2_10_66_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.forsciint.2011.07.001"},{"key":"e_1_2_10_67_1","doi-asserted-by":"publisher","DOI":"10.1258\/msl.2012.012044"},{"key":"e_1_2_10_68_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2020.102056"},{"key":"e_1_2_10_69_1","doi-asserted-by":"publisher","DOI":"10.1016\/s0196\u20100644(97)70072\u20106"},{"key":"e_1_2_10_70_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1748\u20101716.1982.tb07010.x"},{"issue":"1","key":"e_1_2_10_71_1","first-page":"13","article-title":"Evaluation of blood lactate in young men after wingate anaerobic power test","volume":"3","author":"\u00d6zt\u00fcrk M","year":"1998","journal-title":"East J Med"},{"key":"e_1_2_10_72_1","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365\u2010201x.1999.00485.x"},{"issue":"3","key":"e_1_2_10_73_1","first-page":"361","article-title":"Heart rate and blood lactate in 400 m flat and 400 m hurdle running: a comparative study","volume":"43","author":"Gupta S","year":"1999","journal-title":"Indian J Physiol Pharmacol"},{"key":"e_1_2_10_74_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jflm.2014.12.007"},{"key":"e_1_2_10_75_1","doi-asserted-by":"publisher","DOI":"10.4172\/2472\u20101026.1000119"},{"key":"e_1_2_10_76_1","doi-asserted-by":"publisher","DOI":"10.1136\/bjsm.37.3.245"},{"key":"e_1_2_10_77_1","first-page":"207","article-title":"Physiological predictors to lactate dynamics during a wrestling match","volume":"11","author":"Tocilj Z","year":"2015","journal-title":"Arch Budo Sci Martial Arts Extrem Sports"},{"key":"e_1_2_10_78_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1556\u20104029.2007.00500.x"},{"key":"e_1_2_10_79_1","doi-asserted-by":"publisher","DOI":"10.1097\/00000433\u2010199406000\u201000002"},{"key":"e_1_2_10_80_1","doi-asserted-by":"publisher","DOI":"10.1176\/ps.41.7.761"},{"key":"e_1_2_10_81_1","doi-asserted-by":"publisher","DOI":"10.3389\/fnhum.2014.00537"},{"key":"e_1_2_10_82_1","doi-asserted-by":"publisher","DOI":"10.1186\/1471\u2010244X\u201012\u2010221"},{"key":"e_1_2_10_83_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.forsciint.2009.05.012"},{"key":"e_1_2_10_84_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1556\u20104029.2012.02212.x"},{"key":"e_1_2_10_85_1","doi-asserted-by":"publisher","DOI":"10.1080\/17461391.2017.1296890"},{"key":"e_1_2_10_86_1","doi-asserted-by":"publisher","DOI":"10.1080\/10903120390936743"}],"container-title":["Journal of Forensic Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1556-4029.70237","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/1556-4029.70237","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1556-4029.70237","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T04:43:49Z","timestamp":1776055429000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/1556-4029.70237"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,25]]},"references-count":85,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2026,3]]}},"alternative-id":["10.1111\/1556-4029.70237"],"URL":"https:\/\/doi.org\/10.1111\/1556-4029.70237","archive":["Portico"],"relation":{},"ISSN":["0022-1198","1556-4029"],"issn-type":[{"value":"0022-1198","type":"print"},{"value":"1556-4029","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,25]]},"assertion":[{"value":"2025-08-11","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-11-10","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-11-25","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}