Title: Excited Delirium: Recognition and Treatment Joseph Lewis, M.D., Medical Director, Honolulu Emergency Services Division
1Excited Delirium Recognition and
TreatmentJoseph Lewis, M.D., Medical Director,
Honolulu Emergency Services Division
- Excited Delirium a medical condition.
2Excited Delirium
3Excited Delirium Goals
- Understand what is Excited Delirium.
- Understand how patients die from it.
- Understand how to recognize it before patients
die NOTACRIME - Understand how to treat it CHILLBUS
- Understand bonus stuff pathophysiology
4Part 1What is Excited Delirium?
5Excited Delirium Not a Crime
- Historically, a naked, screaming and agitated
individual standing in a busy roadway during rush
hour traffic required law enforcement response. - Police were expected to remove the subject from
the roadway and take him to an appropriate
facility.
6Excited Delirium Not a Crime
- When force was used to subdue the subject,
injuries were common and EMS responded at the
request of the police to treated the injuries. - Medical treatment was focused upon clearing the
subject for incarceration into a jail facility. - Unfortunately, this scenario sometimes resulted
in the untimely and unnecessary death of the
person with excited delirium.
7Unrecognized Excited Delirium is frequently a
violent spiral towards death.
- Victims of excited delirium display sudden onset
of paranoia and alternate between calm behavior
and extreme agitation. - When confronted by police, who are invariably
called to the scene, the victim intensifies the
violence and paranoia. - An intense struggle ensues, when the victim
exhibits incredible "superhuman" strength and is
impervious to the usual police techniques of pain
control, including pepper spray, baton strikes,
and in certain cases TASER deployment.
8Unrecognized Excited Delirium is frequently a
violent spiral towards death.
- The intense struggle requires the efforts of many
police officers, who are finally able to restrain
the victim. - Usually within minutes of being restrained, the
victim loses all vital signs and is suddenly
dead. Core body temperatures average 105 degrees.
- Resuscitation of these cases often results in a
failed course of hospital treatment,
characterized by a fatal sequence of
rhabdomyolysis and renal failure.
9Excited Delirium What is excited delirium?
- It is now known that some of the time this
situation should be viewed as a "medical
crisis" and not a crime. - The person needs medical treatment not
apprehension. - Because the police are usually the first to come
in contact with excited delirium patients during
a call for service involving a subject who is
aggressively violent they need to be trained to
recognize excited delirium.
10Excited Delirium What is excited delirium?
- Law enforcement officers will still be required
to use force to control these patients, however
they also need to be trained to summon help
immediately if they suspect the individual is
suffering from excited delirium symptoms. - By training law enforcement officers and EMTs to
recognize excited delirium we can potentially
reduce the incidence of in custody deaths from
this condition.
11Excited Delirium Not a Crime
- The Key here is the Delirium part
- We must understand the delirium part of excited
delirium. - Delirious people are inattentive, they dont pay
attention. - The part of their brain which helps a person
accurately assesses their surroundings and
respond appropriately to authority figures in a
reasonable manner isnt working. - Their reason appears to have left the building.
12Excited Delirium Not a Crime
- The Key here is the Delirium
- Their reasoning ability has left.
- Their processing capability has left.
- They seem to refuse to listen, when in actuality
they often can hear but cant process. -
- They are suffering from delirium.
13Excited Delirium Not a Crime
- The Key here is the delirium part of excited
delirium. - They not just drunk, high or buzzed, they are
delirious - They arent just rude or disrespectful, theyre
delirious. - This is a medical illness.
14Excited Delirium Not a Crime
- The Key here is the delirium part of excited
delirium. - They respond to all types of stimulation in an
exaggerated fashion, light, sounds cause
agitation and physical touch seems to cause
extreme agitation. - When physically confronted they enter a mode
where they appear to be fighting for their life
and struggle uncontrollably until they suddenly
die.
15Excited Delirium Not a Crime
- Delirium is a medical condition.
- It is a medical illness characterized by a lack
of attention and a lack of processing ability for
visual and auditory stimulus. - That means they see the Police, but they dont
process them as Police. - They hear the officers orders, but they dont
process it. - They respond to physical force with extreme
agitation. - Unless we understand this we get into a physical
confrontation in which they refuse to yield until
they are completely exhausted and or die. - They literally fight to the death.
16Excited Delirium Part 2?
- How Do they Die?
- Why Do they Die?
17What causes Death in Excited Delirium?
- Terms we need to understand to prevent deaths
- Positional Asphyxia
- Compression Asphyxia
- Physiologic issues
- Metabolic issues
- Pre-existing medical conditions
- Stimulant Use
-
18Excited Delirium Not a Crime
- Asphyxia the definition of "asphyxia" is complex
and often means more than hypoxia or lack of
oxygen. - In the legal field of forensic pathology asphyxia
is considered to be a consequence of a struggle
to breathe against some mechanical interference
with respiration.
19Excited Delirium Not a Crime
- Positional Asphyxia is a form of asphyxia
which occurs when body position prevents adequate
breathing, such as from upper airway obstruction
or a limitation in chest wall expansion. It
usually occurs when a person with severe
respiration muscle fatigue is restrained in a
position that impairs or prevents breathing. - This typically occurs when a person is face down.
In this position the person cant breath well due
to the weight of their body on their chest and
their state of exhaustion from vigorous physical
activity. This causes the respiratory arrest
(stops breathing) which is quickly followed by
cardiac arrest (heart stops pumping). They are at
this point clinically dead.
20Excited Delirium Not a Crime
- Compression Asphyxia A form of asphyxia which
occurs when a force or weight prevents adequate
gas exchange, such as a force applied to the
neck, chest or back or due to the weight of his
restrainers on his chest, back or neck. Usually
he is face down and his restrainers are on his
back. Due to the extra weight on the back of the
chest they cant breathe. The more they struggle,
the more weight is added in a endless cycle
ending in death. Combine exhaustion with
restricted breathing and when they cant muster
the energy to take another breathe, respiratory
arrest occurs and is quickly followed by cardiac
arrest. Suddenly their dead. -
21Why Does This Happen?
- These patients are violent and are forcibly
restrained by multiple police officers and after
a usually long struggle, end up hand cuffed,
prone and exhausted in the back seat of a car or
end up prone and exhausted on the ground with
multiple people leaning or laying on them to stop
their combative behavior.
22Excited Delirium Not a Crime
- Positional and compressional asphyxia are terms
frequently heard in civil courtrooms. - Several successful lawsuits have occurred over
deaths while the person was in the prone position
while officers were laying on their back and
other lawsuits were filed when death occurred in
the back of the police car while the person lay
prone on the seat during transport with handcuffs
on. - Almost all in-custody deaths result in some type
of litigation, usually with a focus on the method
of control. - Methods of restraint become issues of contention
in a lawsuit and may be the turning point in the
liability of a law enforcement agency.
23Excited Delirium Not a Crime
- Metabolic issues-acidosis, hyperkalemia
- Pre-existing medical conditions- cardiac
conditions like cardiomyopathy , asthma or COPD - Stimulant Use like methamphetamine or cocaine
- These issues decrease the patients cardiac and
respiratory reserve, so when they are physically
stressed they decompensate and die sooner then if
they were healthy.
24Excited Delirium Deaths
- How big a problems is this?
- It depends on where you live and what the illicit
drugs are used where you live. - Cocaine and methamphetamine are frequently used
by persons who die due to excited delirium.
25Stats on Positional asphyxia
- Los Angeles County
- 216 Case-Hobble Restraint Patient Deaths in one
year - Majority Found Prone by EMS
- All had struggled with the Police
- All had developed labored breathing
- All had unanticipated sudden cardiac arrest
26Part 3 Excited Delirium How do we recognize it
so they dont die?
27Think Excited Delirium when the patient displays
- Sudden Bizarre Behavior
- Hyperactivity
- Combativeness
- Super-Human Strength
- Paranoid Delusions
- Shouting
- Hallucinations
- Hyperthermia
28Other Signs of Excited Delirium
- Inability to Concentrate
- Extreme Restlessness
- Inability to remain still
- Flailing
- Diaphoresis
- Flushed skin
- Extreme Tachycardia
- Shedding of clothes
- Attraction to glass windows or mirrors
29Excited Delirium Not a Crime
- Thats a big list.
- You are probably wondering how you will ever
remember it. - Well it is easier with the following pneumonic.
- Dr. Michael Curtis has developed the following
mnemonic "NOT A CRIME. to characterize this
situation and help law enforcement and EMS
remember the signs and symptoms of excited
delirium.
30Excited Delirium How do we recognize it?
- Naked stripping off clothing and sweating
profusely - Objects recall violence against objects,
especially glass, shiny objects - Tough the person is very strong, unstoppable,
seemingly endless endurance, and a diminished
pain or insensitivity to pain - Acute onset You are told the person just
snapped - Confused The person is unsure who (s)he is,
where (s)he is located, why (s)he is there, and
lacks perception - Resistant The person cannot or refuses to
follow commands to stop his or her behavior. - Incoherent speech The person is shouting
bizarre content - Mental health issues or Makes you feel
uncomfortable - Early EMS request, back-up request, and
supervisor request.
31Excited Delirium How do we recognize it?
- Naked stripping off clothing and sweating
profusely - Objects recall violence against objects,
especially glass, shiny objects - Tough the person is very strong, unstoppable,
seemingly endless endurance, and a diminished
pain or insensitivity to pain - Acute onset You are told the person just
snapped -
32Excited Delirium How do we recognize it?
- Confused The person is unsure who (s)he is,
where (s)he is located, why (s)he is there, and
lacks perception - Resistant The person cannot or refuses to
follow commands to stop his or her behavior. - Incoherent speech The person is shouting
bizarre content - Mental health issues or Makes you feel
uncomfortable, your instincts say mental illness - Early EMS, Police back-up, Supervisor and EMS.
33Excited Delirium How do we recognize it?
- Naked stripping off clothing and sweating
profusely - Objects recall violence against objects,
especially glass, shiny objects - Tough the person is very strong, unstoppable,
seemingly endless endurance, and a diminished
pain or insensitivity to pain - Acute onset You are told the person just
snapped - Confused The person is unsure who (s)he is,
where (s)he is located, why (s)he is there, and
lacks perception - Resistant The person cannot or refuses to
follow commands to stop his or her behavior. - Incoherent speech The person is shouting
bizarre content - Mental health issues or Makes you feel
uncomfortable - Early EMS request, back-up request, and
supervisor request.
34Excited Delirium Not a Crime
- Thus Police, EMS and Fire need to create a
cooperative strategy which treats this as a
medical condition and not a criminal one, and
involves - 1. Early recognition
- 2. Early EMS notification
- 3. Strict avoidance of face down restraint,
- 5. Prompt sedation, cooling and hydration
- 6. Transport to hospital for medical treatment
35Honolulu EMS Protocol Excited Delirium E.D.
- Dispatch Co-respond if Police request.
- Police contact EMS if the person fits the
NOTACRIMINAL Exited Delirium criterion. - Then Patient is
- Restrained by Police and then EMS takes over.
- Remember scene safety and your PPE.
- EMS assessment including vital signs,
temperature, pulse oximetry and blood sugar - EMS communicates with a base station physician
for permission to start CHILBUS protocol
36Management of Excited Delirium
- Personal Protective Equipment
- Scene Safety
- Patient restraint
- Remember you cant help the patient if you become
a patient.
37Restraint
- Physical
- The patient must be restrained first, so you
dont get hurt and they dont hurt themselves! - Chemical
- The goal is chemical restraint to stop the
cascade of struggle, and metabolic deterioration
which leads to death !
38Management of Excited Delirium
- Pneumonic C.H.I.L. B.U.S.
- Calm down Intranasal Versed, then IV Versed or
Valium - Cool down ice packs to armpits, groin and IV
fluids - Hypoxia/Hypoglycemia check pulse oximetry
Accu-chek - IV fluids for cooling, hydration, stop Rhabdo, Rx
lactic H - Lastly dont lay down. Remember B.B.U.S.
- Better
- Breathing
- Upright
- Sitting.
39Calm Down !
- Benzodiazepines are most useful, large doses well
tolerated Ativan Versed. - Haldol and Droperidol can be used, but there use
can cause EPS causing uncontrolled muscle
activity and speeding up the metabolic spiral
towards death, IV use can cause prolongation of
QT causing sudden death from torsades de pointes.
40Cooling
- Cooling is critical
- IV Fluids
- Limit Activity
- Ice Packs Groin and axilla
41IV Fluids for Rehydration
- These patients are hot, sweaty and have extreme
physical activity. - IV hydration helps everything in their metabolic
crisis, acidosis, dehydration, hyperkalemia and
Rhabdomyolysis.
42The End
- The slides which follow are bonus material
43Excited Delirium
-
- The majority of cases of are related to drug use.
- Cocaine seems to be the most common, however
methamphetamine, alcohol, PCP and LSD have also
be documented to cause excited delirium. - Patients suffering from psychiatric illness have
the second highest rates of excited delirium
syndrome and can be related to abrupt cessation
of medications, undiagnosed or treated mania, and
central nervous system adaption to certain
medications. - There are other less common medical causes like
hypoglycemia, hyperthermia, rare types of stroke,
kidney failure or infection like meningitis or
encephalitis.
44Statistically Speaking
- Summer Months
- High Heat and Humidity
- High Body Mass Index
- Methamphetamine or cocaine use
45Statistically Speaking
- Summer Months
- High Heat and Humidity
- High Body Mass Index
- Methamphetamine or cocaine use
46Miami Dade Protocol Excited Delirium E.D.
- Police contact EMS if
- Patient Tasered by Police who fits E.D. criterion
- Then Patient is
- Restrained by Police and then EMS takes over
- Sedation with Nasal Versed then IV Versed
- IV Bolus 2 liters of cold saline
- Sodium Bicarbonate
- Transport to ER with communication Patient enroute
47Pathophysiology of Sudden Death
- What Do We know about the Pathophysiology of
Sudden Death in Excited Delirium
48Lactate
- These patients are struggling, agitated, flailing
and have tremendous muscle activity which
produces large amounts of lactic acid, which
results in. - Severe Metabolic Acidosis
49Rhabdomyolysis
- Muscle Cells disintegrate
- Release muscle enzyme CPK and potassium
- Further alter acid base balance
- Contribute to dangerous electrolyte imbalances
like hyperkalemia or kidney issues due to
rhabdomyolysis
50Hyperkalemia
- Released from inside muscle cells
- Can cause cardiac dysrhythmias
- Must be treated
51Hyperthermia
- These patients have been shown to have
temperatures of 106 degrees ! - No wonder they are frequently found naked or
shedding their clothes.
52Hypoxia
- Mix together stimulant use, acidosis, electrolyte
disturbances like hyperkalemia, Rhabdomyolysis,
hyperthermia and add Hypoxia and you get an
increased risk of sudden death .
53Underlying Medical Conditions
- Things which place the patient at risk of sudden
death with exertion like - Cardiac Disease
- Lung Disease
- Psychiatric Conditions with mania or psychosis
54Hypoglycemia
- Hypoglycemia must be watched for and treated as a
cause of delirium and a complication of continued
agitation
55Hyperkalemia
- IV Fluids
- Bicarbonate
- Dextrose
- Insulin
56Tidbits
- HENDERSON, NV - The 2nd Annual Sudden Death,
Excited Delirium In-Custody Death Conference
focusing upon the latest medical research
findings, theories, and legal issues about
excited delirium, sudden death, electronic
control devices, and jail suicide, which are of
great concern for law enforcement agencies around
the world, will be held on November 28-30, 2007
at the Imperial Palace Hotel, Las Vegas, Nevada.
The three-day Conference is sponsored by the
Institute for the Prevention of In-Custody
Deaths, Inc. (IPICD), Henderson, Nevada.