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Excited Delirium


An unintentional death that occurs while a subject is in custody. ... Death from cocaine overdose and Excited Delirium are not the same condition (the ... – PowerPoint PPT presentation

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Title: Excited Delirium

Excited Delirium
  • Understanding and prevention of sudden custody
    death proximal to restraint

Excited Deliriumdefined
  • A state of extreme mental and physiological
    excitement, characterized by extreme agitation,
    hyperthermia, hostility, exceptional strength and
    endurance without apparent fatigue

In simple terms please
  • Sympathetic nervous system activation
  • Adrenalin pumped into the body
  • Primal fight or flight response
  • The body can only function this way for a limited
  • Similar to putting your car in park and pressing
    the peddle to the floor
  • If it does not slow down eventually you will find
    the weak point in the engine

Sudden in-custody death definition
  • An unintentional death that occurs while a
    subject is in custody. Such deaths usually take
    place after the the subject had demonstrated
    bizarre and/or violent behavior, and has been
  • The death appears similar to sudden death in
    infants. There is no obvious cause of death found
    during initial autopsy.

Typical incident
  • 911 call to Police about a man running in the
    street partially naked and/or acting bizarre
  • Obvious to officers that subject will resist
  • Struggle ensues with multiple officers May
    involve O.C., choke holds, baton, ECD, swarm
  • Physical restraints applied Handcuffs/Hobbles
  • Struggle continues or escalates after restraint
  • Placed in squad for transport to jail

Typical incident continued
  • Apparent resolution period
  • Subject becomes calm or slips into
    unconsciousness (officers believe the subject is
    faking or has finally calmed down)
  • Labored or shallow breathing
  • Followed unexpectedly by death
  • Resuscitation efforts are futile
  • Even when death occurs in the care of paramedics
    or at E.R. resuscitation fails

(No Transcript)
The local media headlines
  • 911 call triggers fatal response as man
    dies after fighting with police officers
  • Local man dies after police use pepper spray
    and a choke hold
  • Man dies in police custody after officers
    used a 50,000 volt TASER

Training goals and objectives
  • Education on sudden custody death
  • Education on Excited Delirium Syndrome
  • Learn to recognize behavioral warning signs of
    Excited Delirium Syndrome
  • Collaborate with Dispatchers, LE, and EMS for
    handling suspected cases
  • Reduce the potential for a sudden custody death
    through training

Focus of training
  • You are not being trained to provide a clinical
  • You are being trained to recognize behavioral
    signs of excited delirium
  • Understand the risks of confrontation
  • If confrontation is necessary, get the subject
    controlled quickly
  • Treat suspected cases as medical emergency

History of sudden death proximal to restraint
  • 1849 Dr. Luther Bell Physician at McLeon Asylum
    (Mass.) documented 40 cases of a peculiar form
    of delirium. excitement with fear or rage
    accompanied with sympathetic nervous system
    arousal. Patients required restraints. Three
    quarters of the cases ended in unexpected

History continued
  • South Carolina Mental Hospital. From 1915-1937
    there were 360 deaths listed as, exhaustion due
    to mental excitement
  • In 1946 Dr. Shulack described this phenomenon as
    sudden exhaustive death in excited manics
  • In 1952 a study by Bellak described the onset
    symptoms of this syndrome
  • The problem continues today in mental
    institutions, nursing homes, and hospitals in
    situations where restraint is necessary

Why the sudden interest?
  • Media attention to people dying in POLICE custody

  • The media and other groups have attempted to
    establish a link between police tactics and
    unexplained deaths
  • Police used force, subject died, therefore
  • Post hoc ergo propter hoc logical fallacy, if
    one event happens after another, then the first
    must be the cause of the second
  • The only things changing are the police
    tools/tactics the underlying factors remain
  • What are some causes? Rise in street drug use
    and a move away from mental institutionalization
    of patients

History of sudden custody death and police tactics
  • Choke holds 1970s through 1980s
  • Hogtie and Positional Asphyxia 1980s through
  • Pepper spray 1990s
  • TASER 2000 to present

Deaths in police custody How common are they?
  • Approx. 200 deaths proximal to police restraint
    per year in the USA (10-20 in Canada) (Dr. Chris
    Lawrence, 2005)
  • Estimated as high as 600-800 per year (DiMaio and
    DiMaio, 2006)
  • 77 die at the scene of their arrest, or while
    being transported to jail cells or hospitals
    (Ross, 1998)

2001 LA study of confinements suspected Excited
  • Stratton, Rogers, Brickett, Gruzinski, 2001
  • 216 arrested subjects exhibiting Excited Delirium

  • 18 deaths, all with struggle forced restraint
  • 78 stimulant drugs
  • 56 chronic disease
  • 56 obese
  • 13/18 died in ALS ambulance, 5 ECD
  • All deaths preceded by less than 5 min quiet
  • What is it about those 18 vs. the 198 survivors?

Common theories of sudden custody death
  • Cardiomyopathy
  • Drug abuse/overdose
  • Restraint/Positional Asphyxia
  • Excited Delirium

  • Heart structural abnormality (predisposed to
    sudden cardiac arrest)
  • Normally not recognized until found in an autopsy
    (inherited trait)
  • Negative lifestyle choices can put person at risk
    of developing condition Alcohol/Drugs
  • Sudden cardiac arrest can occur during times of
    extreme exertion Resisting Arrest

Drug abuse/overdose
  • Recreational drug use (there is no safe dose of
    cocaine,even a small dose can cause death. 1st
    time vs. 150 time)
  • Chronic drug abusers at higher risk (cocaine,
    methamphetamines, PCP, Ephedrine and other
  • Chronic cocaine abuse can lead to Excited
    Delirium (leads to chemical changes in the
    brain, i.e. dopamine receptors and the
  • Death from cocaine overdose and Excited Delirium
    are not the same condition (the toxic overdose
    can lead to the behavioral characteristic of
    excited delirium)

Drug Use Continued
  • Long term use of some prescription drugs can have
    similar affects on the brain
  • Most common of these are psychotropic drugs
    prescribed for mental illness (lithium for
  • Mental illness and excited delirium
  • Bi-polar disorder and schizophrenia

How Excited Delirium can kill
  • Body can only do so much before it literally
    gives out
  • Under normal conditions the brain sends signals
    to the body to stop or calm down as it nears
  • Person experiencing Excited Delirium doesnt have
    or is able to ignore this safety mechanism
  • Can push themselves past exhaustion into
    potentially fatal medical conditions such as
    Metabolic Acidosis and Exertional

Metabolic Acidosis
  • Potentially life-threatening body chemistry
    abnormality caused from a build up of lactic acid
    in the bloodstream
  • Increased lactic acid build up from continual
    resistance or extreme exertion
  • Subject not able to rid themselves of enough CO2

  • Hypoxia lack of oxygen
  • Extremely low blood PH (acidosis )
  • Can lead to cardiac arrhythmia
  • Literally exert themselves to death

Exertional Rhabdomyolysis
  • The continued struggle can deplete the bodys
    normal fuel supply. (A byproduct of metabolizing
    normal body fuel is C02. The body rids itself of
    C02 by breathing. The more you burn the faster
    you breathe. When your body can not get rid of
    enough CO2 through respiration it can lead to
    metabolic acidosis.)
  • When the normal fuel supply is used up the body
    begins to metabolize muscle tissue for fuel
  • The byproducts from burning muscle tissue for
    fuel are toxins released in the blood
  • The kidneys attempt to filter the toxins
  • The toxins can clog up the kidneys (kidney
  • When the kidneys clog up other chemicals can be
    released into the blood and can lead to

Excited Delirium cases increasing
  • Significant rise in street drugs (cocaine,
  • Significant rise in people with mental disorders
    living outside of mental hospitals (taking or
    improperly taking psychotropic medications)
  • More incidents of Excited Delirium
  • The problem is going to get worse
  • Many LE Officers, EMS Medics, Doctors, and
    Medical Examiners lack training in recognition
    and handling of suspected cases

In-custody deaths
  • A growing body of evidence supports that many
    in-custody deaths are not the result of a single
    cause, but a cascade effect of multiple factors
    in motion long before law enforcement ever gets
  • LE gets called when the subject suddenly acts
    bizarre and gets out of control
  • The resulting bizarre behaviors are caused by the
    on-going chemical/medical problems. By the time
    the bizarre behavior occurs they are a long way
    into the medical crisis. The dominos are
    already falling

In-custody deaths
  • The reality is many of the people that die in-
    custody suffer from one or more medical
    conditions that contribute to their mortality
  • Some have high levels of drugs in their bodies
    that cause adverse physical reactions
  • Some are in a mental health crisis (bi-polar
    disorder or schizophrenia)
  • The conditions can be worsened when the subject
    is confronted and restrained by law enforcement

What should we do?
  • Get EMS on the way prior to confrontation if
    possible (emergency response)
  • Avoid confrontation if at all possible
  • Attempt to contain/isolate the subject without
  • Attempt verbal de-escalation
  • Have as many backup officers as possible

  • Bizarre/violent behaviors most often will require
    confrontation and restraint
  • Restraint can make the problem worse
  • Without restraint this medical emergency can not
    be treated
  • Get the fight over quickly (i.e.TASER, swarm)
  • Pain compliance techniques will not work (do not
    use the TASER with cartridge removed, stun mode,
    OC, or other pain compliance techniques)
  • EMS protocols and transport to the hospital

Recognizing behaviors
  • Bizarre, violent, aggressive behavior
  • Violence toward objects
  • Attack/break glass (windows and mirrors)
  • Overheating/excessive sweating or very dry (Body
    shut down perspiration production because of over
    demand on system)
  • Public disrobing -partial or full (cooling
  • Extreme paranoia
  • Incoherent shouting (animal noises or loud
    pressured speech)

Recognize behaviors cont.
  • Unbelievable strength
  • Undistracted by any type of pain (Including
    broken bones and damaged limbs. Can easily
    overpower lone officer)
  • Irrational physical behavior
  • Fight or flight behavior (Subject perceives
    attempts to restrain as threat to his existence.
    It is a primal sympathetic nervous system
  • Hyperactivity
  • Bug Eyes (They look nuts)

(No Transcript)
Early recognition
  • Training for Dispatchers is critical
  • Key questions asked during the 911 call are
  • Information gathered during the 911 call can
    start the recognition process
  • May lead to a simultaneous dispatch of EMS and LE
    which could save valuable time

How do we do this?
  • Excited Delirium training for Dispatchers
  • Develop questions based on behavioral signs of
    excited delirium
  • Establish an Emergency Medical Dispatch protocol
    for this medical condition

Incoming call
  • there is a guy exposing himself on Wis. Ave.
  • Ask questions to draw out description of
  • What specifically is he doing?
  • Bizarre, violent, aggressive behavior
  • Violence toward objects
  • Attack/break glass (windows and mirrors)
  • Overheating/excessive sweating or very dry (Body
    shut down perspiration production because of over
    demand on system)
  • Public disrobing -partial or full (cooling
  • Extreme paranoia
  • Incoherent shouting (animal noises)
  • Unbelievable strength
  • Undistracted by any type of pain (Including
    broken bones and damaged limbs. Can easily
    overpower lone officer)
  • Irrational physical behavior


Follow up questions
  • Does the caller know the subject? If they do,
    what do they suspect is causing the behavior?
  • ? Drug ingestion?
  • 1. type
  • 2. how much
  • 3. when
  • ? Drug history?
  • 1. chronic user
  • 2. what type (stimulants, coke, crack,

Follow up continued
  • Mental illness or psychiatric history
  • 1. bi-polar disorder
  • 2. schizophrenia
  • 3. does subject take meds for
  • 4. medication compliant
  • ? On-set of behaviors
  • 1. sudden (they just went nuts)

If you suspect Excited Delirium
  • Update responding officers
  • Dispatch Patrol Supervisor to the scene
  • Dispatch EMS (Fire?)
  • Advise EMS to stage in the area
  • Keep the caller on the line if possible

What do we do in the mean time?
  • Training
  • Recognize an extremely agitated and/or bizarre
    subject may be experiencing a medical emergency
  • Recognize an excited delirium state is a SYMPTOM
    of advanced physiologic problem that may
    contribute to sudden custody death
  • Treat these cases as a medical emergency
  • Anticipate, recognize, and mobilize EMS before
    confrontation if possible
  • Protocol driven EMS response
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