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

2. Excited Delirium
It’s Chaotic Fury
It’s not just agitation

3. 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

4. Part 1:What is Excited Delirium?

5. 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.

6. 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.

7. 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.

8. 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.

9. 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”.

10. 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 EMT’s to recognize excited delirium we can potentially reduce the incidence of “in custody deaths” from this condition.

11. 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 don’t 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 isn’t working.
“Their reason appears to have left the building”.

12. 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 can’t process.
They are suffering from delirium.

13. 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 aren’t just rude or disrespectful, they’re delirious.
This is a medical illness.

14. 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.

15. 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 don’t process them as Police.
They hear the officers orders, but they don’t 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.

16. How Do they Die? Why Do they Die?
Excited Delirium Part 2?
How Do they Die?
Why Do they Die?

17. 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

18. 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.

19. 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 can’t 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.

20. 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 can’t 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 can’t muster the energy to take another breathe, respiratory arrest occurs and is quickly followed by cardiac arrest. Suddenly their dead.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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

26. Part 3: Excited Delirium How do we recognize it so they don’t die?
Hint: NOTACRIMINAL

27. Think Excited Delirium when the patient displays:
Sudden Bizarre Behavior
Hyperactivity
Combativeness
Super-Human Strength
Paranoid Delusions
Shouting
Hallucinations
Hyperthermia

28. 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

29. Excited Delirium: Not a Crime
That’s 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.

30. 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.

31. 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”

32. 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.

33. 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.

34. 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

35. 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

36. Management of Excited Delirium
Personal Protective Equipment
Scene Safety
Patient restraint
Remember you can’t help the patient if you become a patient.

37. Restraint
Physical
The patient must be restrained first, so you don’t get hurt and they don’t hurt themselves!
Chemical
The goal is chemical restraint to stop the cascade of struggle, and metabolic deterioration which leads to death !

38. 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 don’t lay down. Remember B.B.U.S.
Better
Breathing
Upright
Sitting.

39. 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.

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

41. 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.

42. The End
The slides which follow are bonus material

43. 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.

44. Statistically Speaking
Summer Months
High Heat and Humidity
High Body Mass Index
Methamphetamine or cocaine use

45. Statistically Speaking
Summer Months
High Heat and Humidity
High Body Mass Index
Methamphetamine or cocaine use

46. 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

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

48. 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

49. 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

50. Hyperkalemia Released from inside muscle cells
Can cause cardiac dysrhythmias
Must be treated

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

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

53. 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

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

55. Hyperkalemia
IV Fluids
Bicarbonate
Dextrose
Insulin

56. 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.