Excited delirium

Excited Delirium (ED) is controversial as a cause of death. Also known as the "in-custody death syndrome” and/or “positional asphyxia” ED seems to happen most often to persons restrained by authorities. Some believe it may be a contributory and sometimes preventable factor in death and others believe ED deaths cannot be prevented.

ED victims frequently present with a combination of natural disease (often exacerbated or caused by drug abuse, evidence of chronic drug abuse and/or recent binging of drugs of abuse and positive current blood levels of cocaine or amphetamine (but not overdose levels), and an extremely high core body temperature. History will often include pre-existing psychiatric disorders (with and without drug abuse), and report of extreme behavioral disturbances. The person may have been very agitated, extremely hyperactive, excited, &/or paranoid. They may have shown abnormal strength, not responded to pain and/or have been very aggressive. Response by authorities may have included restraint, chemical sprays, or blows.

While it is acknowledged that a person who may cause harm to themselves, authorities or the public needs to be halted knowledge of presenting features in this syndrome and the likeliness of unexpected death with these presenting features may allow authorities to develop methods that protect the safety of all parties, including the detainee.

Recommendations for dealing with an apparently crazed person include(when possible):

1. Containment rather than restraint
2. Maintenance of an open airway
3. Pressure to arms and legs rather than pressure to the trunk or neck if restraint is needed
4. Limiting time restrained if restraints are used
5. Not placing in a prone position if possible
6. Limiting time in prone position if it is used
7. Not using “hog-tie” restraints
8. Constant observation of a person for continued breathing while restrained
9. Not using neck or choke holds
10. Use of wrist-to-wrist and ankle-to-ankle restraints if restraints are needed
11. Not using chemical sprays or forceful water sprays
12. Not using masks or other covers over the mouth/nose of detainee
13. Not using stun guns
14. Not hitting or kicking detainee
15. Transportation by ambulance to an emergency medical facility, not a psychiatric facility
16. Reduction of external sources of further excitement as much as possible (control of crowd, noise and light extremes)

It is believed that a person already in a compromised physical condition and whacked out on drugs and/or experiencing psychosis can have such an extreme adrenaline response to stress that it can kill them. Things that compromise the ability to breath, such as the prone position or pressure on the trunk or neck, chemical sprays or having the face obstructed not only increase stress but in and of themselves may contribute to the death by decreasing the narrow reserve left in the detainee to cope with the very act of breathing and maintaining a normal heart rhythm.

Police brutality of the Rodney King case’s nature are not part of the syndrome. Normal, legal, procedures of restraint may contribute to death in cases of ED. Balancing the need for safety for the authorities, the public and the detainee from his/her own irrational behavior and the need to treat these cases with a bit more of a kid glove approach is a fine line for authorities. Training is becoming more available and should be sought out by all jurisdictions but some medical examiners believe these deaths are not preventable.

“Epidemiologic findings are most consistent with the hypothesis that chronic cocaine use disrupts dopaminergic function and, when coupled with recent cocaine use, may precipitate agitation, delirium, aberrant thermoregulation, rhabdomyolysis, and sudden death.” From the Journal of Forensic Sciences, 1997

"The most striking finding of this study was that all of those who died unexpectedly during or after an episode of excited delirium had been physically restrained." From Canadian Medical Association Journal CMAJ 1998

Other Sources include:

1. International Association of Forensic Nurses registration brochure for 10th annual conference (If I can’t go to the conference then I can at least research and node it!)
2. http://www.charlydmiller.com/index.html#list (contained scanned copies of articles quoted above)
3. www.salon.com/health/feature/ 1999/09/29/excited_delirium/
4. www.pca.gov.uk/news/docs/ policing%20acute%20behavioural%20disturbance.doc
cocaine.org/hyperthermia/delirium.html
5. www.astm.org/JOURNALS/FORENSIC/PAGES/2565
6. www.newint.org/issue319/update.htm