# Excited Delirium



## Veneficus (May 13, 2010)

Ok, so again I see a JEMS article on this today and want to talk about it.

Does it even exist? What is the mechanism of the pathology? Is there any evidence? Do we know it when we see it? Is it really a different pathology and we are erroneously attributing it to be unique.

So this is what I know.

The original use of excited delirium can be traced to law enforcement. There is unsubstantiated speculation it was used first by non lethal weapon manufacturers. (I bring this up specifically because of the mechanism some of these weapons use, not as a referendum on ther use) 

All of the information I have found on a google search revolves around pro or anti law enforcement. (I don’t care about those arguments at all, I am only interested in the medical aspects.)

Last summer I poured through the records of a local coroner (who is an MD, specifically a pathologist) looking for answers. I was told upfront that excited delirium (ED) cannot be listed as a cause of death and is not a recognized pathology.

I could find no mention of it in any pathology text. 

In my record search, all of the cases where ED was listed as a potential contributing factor, there was positive toxicology test, the substances varied, but crack and cocaine made up a large portion. (exact numbers are at my desk at home, the records are all paper, and I wasn’t wasting luggage space bringing them to school)

My medscape search turned up only examples of cocaine intoxication and sudden death. 

I contacted both forensic and biological anthropologists who could not recall any example in nonhuman primates of such conditions. 

I contacted a zoologist who could not give me one example of such description in the animal kingdom.

In all of the pro ED internet articles, some form of substance was reported. 
This leads me to the conclusion that what we may witness or term ED is actually a sudden death from the release of and failure of breakdown/reuptake of neurotransmitters. Basically the entire store of catecholamines are released and by blocking of reuptake, dissipate into surrounding tissue. I have no proof, I can find no study, it is just my conjecture.

Could other medications with similar mechanism cause a similar effect? (like psychiatric meds or neurological treatments?)

What is your conjecture? Have you witnessed it? Would you describe what you observed and learned afterword?


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## Smash (May 13, 2010)

Veneficus said:


> Ok, so again I see a JEMS article on this today and want to talk about it.
> 
> Does it even exist? What is the mechanism of the pathology? Is there any evidence? Do we know it when we see it? Is it really a different pathology and we are erroneously attributing it to be unique.
> 
> ...



Excited Delirium is not a term that is used where I work, and I suspect that no-one would have a clue what you were talking about if it were to be used.  There are certainly situations where patients under the influence of psycho-stimulants may be aggressive, agitated, have blunted response to pain and all those sorts of things.  However this is simply an issue of toxicity rather than some magic syndrome of excited delirium.  

My supposition would be that a reasonable number of these patients may be suffering from a serotonin syndrome related to abuse of medications that alter neurotransmitter activity.  My understanding is that the drugs that are typically involved in 'excited delirium' are all very good at modulating dopamine, adenosine, noradrenaline, GABA, 5HTP and so forth.  Whilst serotonin syndrome is relatively rare, it does have the distinct advantage of being something that actually exists...

EDIT:  Sorry, I forgot.  Yes I have encountered a reasonable number of patients under the effect of psycho-active drugs who have required management and sometimes restraint, either physical or chemical or both.  Each and every one of them have either been under the influence of various drugs and/or had significant psychiatric histories AND been under the influence of drugs.  These have been distinct from the cases of psychosis related to organic brain disease without the confounding influence of drugs (except of course marijuana as is often the case as they attempt to self-medicate), some of whom have required similar management to allow safe transport and assessment.


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## MrBrown (May 13, 2010)

Could we be dealing with some massive sympathetic overload where people simply conk out and have a massive neuro or heart storm and die?

Some people are on drugs and some have predisposed mental illness; both of which wouldn't help.

In the cases where people are buried beneath twenty overzealous cops wouldn't that leave some sort of hypoxia induced acidosis as a cause of death?

We have had one or two cases here where basically the cops have had a fight with somebody and when they're restrained him he's up and died.  The cause of death has been either suffocation or a cardiac arrest.


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## Smash (May 13, 2010)

MrBrown said:


> Could we be dealing with some massive sympathetic overload where people simply conk out and have a massive neuro or heart storm and die?
> 
> Some people are on drugs and some have predisposed mental illness; both of which wouldn't help.
> 
> ...



Positional or restraint asphyxia is a likely cause of these deaths.


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## bfog99 (May 14, 2010)

I wrote a position paper on this topic when I went thru medic school. In all the cases I looked at, it was deemed that positional asphyxia was the contributing factor in death, not the excited dilerium or the intoxicants the victim was on.


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## firetender (May 14, 2010)

As far as I know, ED is what I get all these e-mails about and if I take their drugs (a lot of which are much cheaper from Canada or Mexico) then, ED is something I'll never have to be concerned with, and my most intimate partners will be more than happy in the time they spend with me.

That having been said...How would that present in the field and would that even be something important to look for?

What would you be called to the scene for, what would you be likely to find, how would you intervene in the time you have at the scene, and what would you be likely to encounter in the back of the ambulance en route to the hospital?

In other words, what's the clinical presentation and what is the intervention on our part, because really, we don't diagnose; we respond by taking actions that stabilize the patient as best we can between the scene and the hospital. Does it really matter to medics if they understand something that may happen to show up on the autopsy report?

I'm interested in the subject, Vene, but I couldn't catch the picture you were trying to paint. It was like coming into the movie 30 minutes late.


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## mycrofft (May 14, 2010)

*Nurse Detox here...*

The wikipedia article makes it sound like a BS homebrew from a Florida coroner. However...the general scenario just sounds like a PCP berzerker (and usually they are not on just one drug) who keeps upping the ante when in confrontation with law enforcement because of psychoactive meds and the particular drugs' effects dissociating or masking pain/distress.
I would guess COD to be positional asphyxia exacerbated by rhabdomyolysis (probably predating arrest), potentially preextant cardio defects or an intracranial event. Only the knife and the test tube can tell.

We did have a run of individually arrested guys who were all early middle aged and from Vietnam who were arrested for being publicly intoxicated, resisted arrest with mild to moderate force, and did NOT respond to pepper spray. They were brought in when two officers could rassle them and cuff 'em, then washed down, and brought to us to watch. Their affect during the altercation and spraying was laughing and singing (sic). No idea except they had opium on board. The next day they were sore and didn't remember the prior day.

Big note is to remember that most fights are won when one person gives up, not when they are physically disabled. When a medication, metabolic problem or psychiatric disorder creates rage and raises the "give up" threshhold above the "get dead" threshold, deaths will occur.


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## mycrofft (May 14, 2010)

*PS: Very funny, firetender. "ED" indeedy!*

........<_<


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## firetender (May 14, 2010)

mycrofft said:


> ........<_<



But seriously I've had experience with this sort of thing. I've brought this up here before. I've had a couple of cases like this, one in Daytona, FL and the other in Santa Barbara, CA. But neither had fatal results. Why? Because something "old school" seemed to work.

In both cases, drugs were involved, there were Police on the scene either attempting to or having just tried restraining the individual who was unable to be restrained no matter how many cops jumped him. We're talking 4 to 6 cops at a time.

In both cases, I observed the patients who were on their feet, the cops having backed off for a breather in-between assaults. The pts. were hyperventillating. 

In the absence of the cops rushing them, however, I observed that their breathing would slow down. A threatening remark would be made and the patient would start hyperventillating again and burst into violent activity.

In both cases, I waited for a lull, slowly approached the persons, ID'd myself as a good guy there to just make sure he was all right and talk, and then convinced them to re-breathe into a paper bag. Initial presentation showed elevated BP which, as they calmed down, dropped to WNL.

In both cases, the patients calmed down and I got permission from the cops to bring them to the hospital because of a medical crisis that could lead to death; at the time thinking only in terms of the treatment most needed by the patient was a cop-ectomy.

Got them alone into the rig, PD followed us in. They got what they wanted, I got what I wanted; no more cops hurt, no further damage to the patient.

***********************************
Now I've seen other medics work this stuff, equally as aggressive as the cops and toss the people into the Police Car. They kept thrashing about like tuna, ripping the interior of the car to shreds.

I've also seen medics "sandwich" such patients on the gurney with a FW "scoop" stretcher on top of them and watched as the hyperventillation continued and their body was in an almost constant state of tension and fight, except for periods of near apnea.

Ain't this enough to push someone over the edge if the external pressure continues, exacerbating the internal "On" switch induced by drugs?


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## Sandog (May 14, 2010)

Hmm, after some reading, this term seems to be somewhat controversial. I did look it up on my schools library website. Here is an excerpt from one of the articles.



> In all 21 cases of unexpected death associated with excited delirium, the
> deaths were associated with restraint (for violent agitation and hyperactivity),
> with the person either in a prone position (18 people [86%]) or subjected to pressure
> on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity
> ...



I downloaded the full articles as pdf but since they are not made public domain, I do not think it appropriate to post the full pdf's here. If you would like the full article then PM me, if that is possible for a newb to post pdf's in a PM.


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## mycrofft (May 14, 2010)

*Firetender: heck yeah!*

I was commentng upon the Viagra double entendre!


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## mycrofft (May 14, 2010)

*Sandog, here*

http://www.cmaj.ca/cgi/reprint/158/12/1603.pdf

If it's on GOOGLE, it's fair use if you don't charge for it.


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## mycrofft (May 14, 2010)

*Ah, post-prandial.*

Looks ike "excited delireum" is not necessarily a capitalized syndrome unless/until the Floridian med examiner makes it so.


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## Veneficus (May 14, 2010)

Sandog said:


> Hmm, after some reading, this term seems to be somewhat controversial. I did look it up on my schools library website. Here is an excerpt from one of the articles.
> 
> 
> 
> I downloaded the full articles as pdf but since they are not made public domain, I do not think it appropriate to post the full pdf's here. If you would like the full article then PM me, if that is possible for a newb to post pdf's in a PM.



The issue is that groups like law enforcement and EMS are referring to excited delirium like it is an actual pathology. Which there is absolutely no evidence of. 

It is like attributing the sun coming up to a guy riding a firey chariot. 

as several people here pointed out, including your own statement, death was caused or accelerated by already known (aka recognized) pathologies. 

Providers are referring to and teaching about excited delirium. To me, without evidence or even a proposed mechanism it is like saying "the patient died because of magic." Then (I'll be generous) the pseudoscience is touted like fact to the point it is written about in trade journals. That really devastates the case EMS is either medical or scientific.


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## Sandog (May 14, 2010)

I think the term "excited delirium" is used more as a term to describe an acute behavior as opposed to a medical diagnosis of an illness.  Albeit there may be an underlying physical manifestation to this unexplained outburst of inappropriate behavior and sudden death, I doubt there is much study on this subject as it would be very problematic to conduct.  For one, how would you find patients to test as this occurrence seems rare and under very certain circumstances. If one were to find a person prone to this condition it would be highly unethical to attempt a ED response as the outcome could be death.

Just curious, was this subject brought up as an assignment? Just wondering what sent you on this quest. Interesting never the less.


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## Veneficus (May 14, 2010)

Sandog said:


> Just curious, was this subject brought up as an assignment? Just wondering what sent you on this quest. Interesting never the less.



It was not an assignment, I never get assignments so easy...

I brought it up because the topic seems to spring up out of nowehere from time to time. Most of the debate associated with it seems to be a back and forth between people who think it is a cover up for improper use of force and an explanation by those using force to relieve themselves of responsibility of the death.

Being neither pro nor anti I hope to stimulate an objective look and constructive academic debate on the matter.

All behavior is biochemically mediated, so if it is a behavioral issue, then there must be a biochemical process governing it that can fail. That would make it a pathology. 

EMS also has a dangerous habit of making things up and then preaching it as fact despite little or no supporting evidence or evidence to the contrary.

It is possible to witness an event and accurately recount it but be mistaken as to the mechanism of how it occured.

I described somewhere else how it is possible that new behaviors or pathologies can draw out latent ones. I used Kaposi's Sarcoma as an example. Prior to the AIDs epidemic, it was an extraordinarlily rare disease. However, like many other diseases, the compromised individual is predisposed to it now.

As another facet of the issue, in the US, "humane" physical restraint is often tried before chemical restraint or outright violent restraint (like beating into unconsciousness). In other countries that is not the case. That would explain why it is not seen or not recognized outside of the US.

The lack of overwhelming physical force may perpetuate neurologic stress stimulation that we already know is harmful over long periods. (it is why stressed people suffer more diseases) If that is the case, it really would be safer to just club somebody down as soon as possible rather than to tazer, pepper spray, or restrain people in the currently accepted medical practices.

research, hypothesis, and academic debate are the hallmarks of educated professions. We have made an observation, it is rare, but common enough to have a name. We should make every effort to investigate it.


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## Sandog (May 15, 2010)

> It was not an assignment, I never get assignments so easy...



Hardly an easy assignment I would say, and did not mean to imply that you are a beginning student, rather a person continuing the education process needed in this field.  

I agree with you that this behavior deserves further research and study. A sound hypothesis would be nice, but you and I both know that a hypothesis is only as solid as the test performed to support it and as I stated previously, testing of any hypothesis on this subject would be a violation of ethical standards. For now we will have to go on empirical research I think.


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## Aidey (May 15, 2010)

From the bit of research I've done excited delerium seems like something someone came up with to explain a set of symptoms without first having a distinct set of symptoms, a test for it or even a distinct pathology. Just because two events have the same outcome doesn't mean they were caused by the same thing. As was pointed out above when the cases are examined there are a few different pathologies that keep popping up; Drugs, heart disease, positional asphyxia etc. 


It honestly reminds me of what I've read on fibromyalgia. I don't doubt the people are in pain, but I've seen patients who are diagnosed with it who are dying of AIDS, Hep C or cancer. Also patients who have diabetes, severe arthritis or any other number of already painful conditions. It would not surprise me if in the future they find out that fibromyalgia isn't one condition, but dozens of different conditions all being lumped together.


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## Sandog (May 15, 2010)

Be it skeptic or other, fact of the matter is that these people end up dead for no clear explainable reason. Not quite the same as the fibromyalgia craze created by the alternative medicine practitioners. From another article I found.



> The term Excited Delirium (also known as Bell's
> mania, lethal catatonia, acute exhaustive mania, agitated
> delirium) was first used in 1849' to describe psychiatric
> patients who developed continuous agitation and mania
> ...



http://blog.ocsd.org/file.axd?file=Excited+Delirium+-+July+2007.pdf

Clearly this condition has been noted since the early nineteenth century and all of these past cases can not possibly be due to police abuse or some other form of cover up.  

With cases of ED dating back as far as 100 years, we should take pause. One may argue that drugs are usually involved but lets not forget that cocaine use was quite common in the 1800's. 

I think the elevated temp and change in skin tone are a few major physiological symptom and maybe more exist. With awareness, this condition may produce more documented symptoms which may eventually lead to a methodology in dealing with such patients and ultimately a reduced number of deaths.


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## Veneficus (May 15, 2010)

Sandog said:


> Hardly an easy assignment I would say, and did not mean to imply that you are a beginning student, rather a person continuing the education process needed in this field.



No worries, I guess I could have better explained myself. Usually my assignments have to have an answer to something. Musing on something not under a deadline or with immediate and direct consequence of life or health is rather easy.  



Sandog said:


> I agree with you that this behavior deserves further research and study. A sound hypothesis would be nice, but you and I both know that a hypothesis is only as solid as the test performed to support it and as I stated previously, testing of any hypothesis on this subject would be a violation of ethical standards. For now we will have to go on empirical research I think.



It wouldn't be the first pathologial description or medical treatment supported only by expert opinion. 



Sandog said:


> ...which may eventually lead to a methodology in dealing with such patients and ultimately a reduced number of deaths.



That is the goal. 

Your post however, points again to an overstimulated biochemical process. 

It also backs up my idea that current practices are intensifying the frequency of latent pathology. 

Coupled with the position the condition is not witnessed in other species, it would seem to point to an origin of higher function in the brain being stimulated. Which leads to the logical conclusion that a quicker "less humane" way of incapacitating people might actually be a solution to reducing mortality. 

Sun Tzu would be proud, " ...a swift and powerful offense..."


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## MrBrown (May 15, 2010)

New Zealand Police do not routintely carry firearms on thier person (although they have access to them) and have introduced the Taser as a step between OC spray/ASP batons and using leathal force.

The move has been debated here somewhat with all the "anti-Taser" people jumping up and down screaming bloody murder.  ... and how long has Nana been able to buy a stun gun? What's a stun gun you ask? Why it's a Taser with no barbs!

I say "excited delerium" is just a massive hyper sympathetic response which causes some sort of heart or brain storm and poof they drop dead.


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## DT4EMS (May 17, 2010)

Excited Delirium is a phenomenon considered a true medical emergency. It is a recognized brain disorder usually caused by high levels of alcohol intoxication or the ingestion of drugs like cocaine, methamphetamine and PCP. Although drugs are usually present in the system of a person exhibiting signs of excited delirium, there have been documented cases where no drugs were present in the patient’s system. (1)

EMS providers may be called to a scene by law enforcement to care for a patient who resisted arrest and is in the custody of law enforcement.  Any time EMS is dispatched to a scene where a subject was known to resist law enforcement the EMS provider should suspect Excited Delirium. With some of the current training for law enforcement, EMS may be dispatched prior to the subject being in custody. For this reason, EMS should stage per local protocol until the subject is in custody and officers declare the scene secure. 

With the safety of the EMS provider paramount, look for or receive the report of a sudden onset of bizarre and/or aggressive behavior. The patient may be shouting and exhibiting signs of paranoia. You may observe panic behavior with an attitude of violence toward others (specifically authority figures like police). There are numerous reports of people experiencing Excited Delirium having unexpected physical strength.

 It may have been reported to have taken several officers, using a variety of tools (Mace, Taser, and baton strikes) and tactics to subdue the subject. It is reported that people experiencing Excited Delirium will be hyperthermic and tend to disrobe. Over 95% of all cases are reported to be males.  

So, imagine a person, uninvolved, who walks up to your crash scene yelling about being stuck in traffic. He is loud and very animated. He is waving his arms and appears to be sweating profusely. He rips off his shirt, balls up his fists and challenges EMS and law enforcement. His speech is loud, rambling and sometimes in-coherent. The subject in this scenario is similar to a video circulating on the internet of an Oklahoma EMS crew assaulted at a crash scene.

Not all excited delirium cases are fatal but some are. In the cases of Fatal Excited Delirium, the patient appears  clinically to consist of 4 distinct phases, which occur sequentially. 

First there is an elevated temperature. Second is the onset of the agitated/excited delirium. Next comes respiratory arrest followed by death.(2) It is because of the recognition of these stages law enforcement agencies are training their officers to call for EMS response early when dealing with a person experiencing Excited Delirium. Officers have a responsibility to protect the subject after he is taken into custody. 

Knowing the possibility of death can occur, the officers will enlist the help of EMS, since there is a belief that many in-custody deaths were a result of Fatal Excited Delirium. Police are being trained that unless the person experiencing Excited Delirium is a threat to others, he is more of a medical problem than that of a law enforcement one.


1)	http://www.exciteddelirium.org accessed 03-02-2010
2)	Wetli CV, Mash D, and Karch SB. Cocaine-Associated Agitated Delirium and the Neuroleptic Malignant Syndrome. Am J Emerg Med 1996; 14: 425 - 428.


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