Excited Delirium: Recognition and Treatment Joseph Lewis, M.D., Medical Director, Honolulu Emergency Services Division

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Excited Delirium Recognition and
TreatmentJoseph Lewis, M.D., Medical Director,
Honolulu Emergency Services Division

• Excited Delirium a medical condition.

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Excited Delirium

• Its Chaotic Fury

• Its not just agitation

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Excited 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

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Part 1What is Excited Delirium?
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Excited 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.

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Excited 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.

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Unrecognized 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.

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Unrecognized 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.

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Excited 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.

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Excited 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.

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Excited 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.

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Excited 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.

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Excited 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.

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Excited 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.

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Excited 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.

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Excited Delirium Part 2?

• How Do they Die?
• Why Do they Die?

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What 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

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Excited 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.

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Excited 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.

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Excited 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.

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Why 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.

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Excited 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.

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Excited 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.

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Excited 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.

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Stats 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

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Part 3 Excited Delirium How do we recognize it
so they dont die?

• Hint NOTACRIMINAL

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Think Excited Delirium when the patient displays

• Sudden Bizarre Behavior
• Hyperactivity
• Combativeness
• Super-Human Strength
• Paranoid Delusions
• Shouting
• Hallucinations
• Hyperthermia

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Other 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

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Excited 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.

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Excited 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.

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Excited 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

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Excited 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.

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Excited 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.

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Excited 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

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Honolulu 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

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Management of Excited Delirium

• Personal Protective Equipment
• Scene Safety
• Patient restraint
• Remember you cant help the patient if you become
  a patient.

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Restraint

• 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 !

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Management 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.

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Calm 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.

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Cooling

• Cooling is critical
• IV Fluids
• Limit Activity
• Ice Packs Groin and axilla

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IV 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.

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The End

• The slides which follow are bonus material

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Excited 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.

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Statistically Speaking

• Summer Months
• High Heat and Humidity
• High Body Mass Index
• Methamphetamine or cocaine use

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Statistically Speaking

• Summer Months
• High Heat and Humidity
• High Body Mass Index
• Methamphetamine or cocaine use

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Miami 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

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Pathophysiology of Sudden Death

• What Do We know about the Pathophysiology of
  Sudden Death in Excited Delirium

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Lactate

• These patients are struggling, agitated, flailing
  and have tremendous muscle activity which
  produces large amounts of lactic acid, which
  results in.
• Severe Metabolic Acidosis

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Rhabdomyolysis

• 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

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Hyperkalemia

• Released from inside muscle cells
• Can cause cardiac dysrhythmias
• Must be treated

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Hyperthermia

• These patients have been shown to have
  temperatures of 106 degrees !
• No wonder they are frequently found naked or
  shedding their clothes.

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Hypoxia

• Mix together stimulant use, acidosis, electrolyte
  disturbances like hyperkalemia, Rhabdomyolysis,
  hyperthermia and add Hypoxia and you get an
  increased risk of sudden death .

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Underlying 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

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Hypoglycemia

• Hypoglycemia must be watched for and treated as a
  cause of delirium and a complication of continued
  agitation

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Hyperkalemia

• IV Fluids
• Bicarbonate
• Dextrose
• Insulin

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Tidbits

• 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.