Excited delirium

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Excited delirium
Other namesExcited delirium syndrome, agitated delirium, Sudden death in restraint syndrome
PinelRestaint.jpg
An example of physical restraints which may be used until chemical sedation takes effect.
SpecialtyEmergency medicine, psychiatry
SymptomsAgitation, delirium, sweating[1]
ComplicationsRhabdomyolysis, high blood potassium[1]
CausesSubstance use, mental illness[1]
Differential diagnosisLow blood sugar, heat stroke, thyrotoxicosis, paranoid schizophrenia, bipolar disorder[1]
TreatmentSedation, cooling, intravenous fluids[1]
MedicationKetamine or midazolam and haloperidol[2]
PrognosisRisk of death < 10%[1]
FrequencyUnknown[1]

Excited delirium (EXD), also known as agitated delirium, is a syndrome described as a combination of psychomotor agitation, delirium, and sweating.[1] It may include attempts at violence, unexpected strength, and very high body temperature.[3] Complications may include rhabdomyolysis or high blood potassium.[1]

Excited delirium is not recognized by the World Health Organization, the American Psychiatric Association, or the American Medical Association, and therefore not listed as a medical condition in the Diagnostic and Statistical Manual of Mental Disorders.[4]

The UK Independent Advisory Panel on Deaths in Custody (IAP) suggests that the syndrome should be termed “Sudden death in restraint syndrome” in order to enhance clarity.[5] Examples of deaths due to the condition are found primarily in restraint or attempted restraint situations, while medical preconditions and symptoms attributed to the syndrome are far more varied.[1][5]

Definitions and symptoms[edit]

EXD has been accepted by the American College of Emergency Physicians, who argue in a 2009 white paper that "excited delirium" may be described by several codes within the ICD-9.[6] A November 2012 The Journal of Emergency Medicine literature review says that the American College of Emergency Physicians Task Force reached consensus, based on "available evidence, that Excited Delirium Syndrome (EDS) is a "real syndrome with uncertain, likely multiple, etiologies."[1]

According to one 2020 publication, "excited delirium syndrome" is a "clinical diagnosis" with symptoms including delirium, psychomotor agitation, and hyperadrenergic autonomic dysfunction.[7]

The diagnosis was not in the 2013 Diagnostic and Statistical Manual of Mental Disorders-5 or the 1992 International Classification of Diseases.[1][8]

Treatment and prognosis[edit]

Treatment initially may include ketamine or midazolam and haloperidol injected into a muscle to sedate the person.[2] Rapid cooling may be required in those with high body temperature.[1] Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful.[1] One of the benefits of ketamine is its rapid onset of action.[9] The risk of death among those affected is less than 10%.[1] If death occurs it is typically sudden and cardiac in nature.[1] Concern has been raised by some medical professionals about the increasing usage of a claim of excited delirium to justify tranquilizing persons during arrest, with requests for tranquilization often being made by law enforcement rather than medical professionals. Ketamine is the most commonly used drug in these cases.[10]

Epidemiology[edit]

How frequently cases occur is unknown.[1] Males account for more documented diagnoses than females.[11] Deaths associated with the condition are typically males with an average age of 36.[1] Often law enforcement has used tasers or physical measures in these cases, and death most frequently occurs after the person is forcefully restrained.[1]

Signs and symptoms[edit]

The signs and symptoms for excited delirium may include:[12][13][14][15]

Cause[edit]

Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic substance use disorder, particularly stimulant drugs such as cocaine and MDPV.[6][16][17] Alcohol withdrawal or head trauma may also contribute to the condition.[13] Physical struggle, especially if prolonged, has been shown to greatly exacerbate many of the harmful symptoms such as metabolic acidosis, hyperthermia, catecholamine surge, and tachycardia.[1] A majority of fatal cases involved men in a law enforcement or restraint situation.[1]

People with excited delirium frequently have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine.[12] Other drugs that may contribute to death are antipsychotics.[18][19][20]

The cause is often related to long-term substance use or mental illness.[1] Commonly involved drugs include cocaine, methamphetamine, or certain substituted cathinones.[3] In those with mental illness, rapidly stopping medications such as antipsychotics may trigger the condition.[1]

Mechanisms[edit]

The pathophysiology of excited delirium is unclear,[14] but likely involves multiple factors.[21] These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal abnormal heart rhythms.[21] The underlying mechanism may involve dysfunction of the dopamine system in the brain.[3]

Diagnosis[edit]

Key signs of excited delirium are aggression, altered mental status, and diaphoresis/hyperthermia.[22]

Other conditions which can resemble excited delirium are mania, neuroleptic malignant syndrome, hypoglycemia, thyroid storm, and catatonia of the malignant or excited type.[23][22]

History[edit]

In 1849 a similar condition was described by Luther Bell as "Bell's mania".[1][24] The first use of the term "excited delirium" (EXD) was in a 1985 Journal of Forensic Sciences article, co-authored by coroner, Charles V. Wetli, entitled "Cocaine-induced psychosis and sudden death in recreational cocaine users".[25][26][1] The JFS article reported that in "five of the seven" cases they studied, deaths occurred while in police custody.[26]

Controversy related to policing techniques[edit]

The condition is not recognized by the American Psychiatric Association, American Medical Association or the World Health Organization.[27][28][29] Critics of excited delirium have stated that the condition is primarily attributed to deaths while in the custody of law enforcement and is disproportionately applied to black and Hispanic victims.[27][30][31] Eric Balaban of the American Civil Liberties Union argued in 2007 that the diagnosis served "as a means of white-washing what may be excessive use of force and inappropriate use of control techniques by officers during an arrest."[4]

Taser use[edit]

Some civil-rights groups argue that excited delirium diagnoses are being used to absolve law enforcement of guilt in cases where alleged excessive force may have contributed to patient deaths.[32][33][34] In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.[34]

In Canada, the 2007 case of Robert Dziekanski received national attention and placed a spotlight on the use of tasers in police actions and the diagnosis of excited delirium. Police psychologist Mike Webster testified at a British Columbia inquiry into taser deaths that police have been "brainwashed" by Taser International to justify "ridiculously inappropriate" use of the electric weapon. He called excited delirium a "dubious disorder" used by Taser International in its training of police.[35] In a 2008 report, the Royal Canadian Mounted Police argued that excited delirium should not be included in the operational manual for the Royal Canadian Mounted Police without formal approval after consultation with a mental-health-policy advisory body.[36]

A 2010 systematic review published in the Journal of Forensic and Legal Medicine argued that the symptoms associated with excited delirium likely posed a far greater medical risk than the use of tasers, and that it seems unlikely that taser use significantly exacerbates the symptoms of excited delirium.[37]

See also[edit]

References[edit]

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y Vilke GM, DeBard ML, Chan TC, Ho JD, Dawes DM, Hall C, et al. (November 2012). "Excited Delirium Syndrome (ExDS): defining based on a review of the literature". The Journal of Emergency Medicine. 43 (5): 897–905. doi:10.1016/j.jemermed.2011.02.017. PMID 21440403.
  2. ^ a b Gerold KB, Gibbons ME, Fisette RE, Alves D (2015). "Review, clinical update, and practice guidelines for excited delirium syndrome". Journal of Special Operations Medicine. 15 (1): 62–9. PMID 25770800.
  3. ^ a b c Mash DC (2016). "Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum". Frontiers in Physiology. 7: 435. doi:10.3389/fphys.2016.00435. PMC 5061757. PMID 27790150.
  4. ^ a b Sullivan L. "Death by Excited Delirium: Diagnosis or Coverup?". NPR. Archived from the original on March 2, 2007. Retrieved February 26, 2007. You may not have heard of it, but police departments and medical examiners are using a new term to explain why some people suddenly die in police custody. It's a controversial diagnosis called excited delirium. But the question for many civil liberties groups is, does it really exist?
  5. ^ a b Baker D (December 1, 2018). "Making Sense of 'Excited Delirium' in Cases of Death after Police Contact". Policing: A Journal of Policy and Practice. 12 (4): 361–371. doi:10.1093/police/pax028.
  6. ^ a b ACEP Excited Delirium Task Force (September 10, 2009). "White Paper Report on Excited Delirium Syndrome" (PDF). American College of Emergency Physicians.
  7. ^ Sekhon S, Fischer MA, Marwaha R (2020). "Excited (Agitated) Delirium". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 31536280. Retrieved June 8, 2020.
  8. ^ Vilke GM, Payne-James JJ (2016). Current Practice in Forensic Medicine. John Wiley & Sons, Ltd. pp. 97–117. doi:10.1002/9781118456026.ch6. ISBN 9781118456026.
  9. ^ Mankowitz SL, Regenberg P, Kaldan J, Cole JB (November 2018). "Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis". The Journal of Emergency Medicine. 55 (5): 670–681. doi:10.1016/j.jemermed.2018.07.017. PMID 30197153.
  10. ^ Sidner S, Jones J. "Two strangers, with the same first name, and a terrifying story about ketamine in policing". CNN. Retrieved September 28, 2020.
  11. ^ Gonin P, Beysard N, Yersin B, Carron PN (May 2018). "Excited Delirium: A Systematic Review". Academic Emergency Medicine. 25 (5): 552–565. doi:10.1111/acem.13330. PMID 28990246.
  12. ^ a b Grant JR, Southall PE, Mealey J, Scott SR, Fowler DR (March 2009). "Excited delirium deaths in custody: past and present". The American Journal of Forensic Medicine and Pathology. 30 (1): 1–5. doi:10.1097/PAF.0b013e31818738a0. PMID 19237843. S2CID 205910534.
  13. ^ a b Samuel E, Williams RB, Ferrell RB (2009). "Excited delirium: Consideration of selected medical and psychiatric issues". Neuropsychiatric Disease and Treatment. 5: 61–6. doi:10.2147/ndt.s2883. PMC 2695211. PMID 19557101. Archived from the original on July 16, 2011.
  14. ^ a b Hoffman L (November 2009). "ACEP Recognizes Excited Delirium as Unique Syndrome". Emergency Medicine News. 31 (11): 4. doi:10.1097/01.EEM.0000340950.69012.8d. S2CID 220585342.
  15. ^ "Excited Delirium.org: For Law Enforcement". University of Miami. Archived from the original on July 26, 2011. Retrieved July 1, 2011.
  16. ^ SoRelle R (October 2010). "ExDS Protocol Puts Clout in EMS Hands". Emergency Medicine News. 32 (10): 1, 32. doi:10.1097/01.EEM.0000389817.48608.e4.
  17. ^ Penders TM, Gestring RE, Vilensky DA (November 2012). "Intoxication delirium following use of synthetic cathinone derivatives". The American Journal of Drug and Alcohol Abuse. 38 (6): 616–7. doi:10.3109/00952990.2012.694535. PMID 22783894. S2CID 207428569.
  18. ^ Minns AB, Clark RF (November 2012). "Toxicology and overdose of atypical antipsychotics". The Journal of Emergency Medicine. 43 (5): 906–13. doi:10.1016/j.jemermed.2012.03.002. PMID 22555052.
  19. ^ Levine M, Ruha AM (July 2012). "Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management". CNS Drugs. 26 (7): 601–11. doi:10.2165/11631640-000000000-00000. PMID 22668123. S2CID 24628641.
  20. ^ Wang PS, Schneeweiss S, Setoguchi S, Patrick A, Avorn J, Mogun H, et al. (December 2007). "Ventricular arrhythmias and cerebrovascular events in the elderly using conventional and atypical antipsychotic medications". Journal of Clinical Psychopharmacology. 27 (6): 707–10. doi:10.1097/JCP.0b013e31815a882b. PMID 18004143.
  21. ^ a b Otahbachi M, Cevik C, Bagdure S, Nugent K (June 2010). "Excited delirium, restraints, and unexpected death: a review of pathogenesis". The American Journal of Forensic Medicine and Pathology. 31 (2): 107–12. doi:10.1097/PAF.0b013e3181d76cdd. PMID 20190633. S2CID 38847396.[dead link]
  22. ^ a b Vilke GM, Bozeman WP, Dawes DM, Demers G, Wilson MP (April 2012). "Excited delirium syndrome (ExDS): treatment options and considerations". Journal of Forensic and Legal Medicine. 19 (3): 117–21. doi:10.1016/j.jflm.2011.12.009. PMID 22390995.
  23. ^ Samuel E, Williams RB, Ferrell RB (2009). "Excited delirium: Consideration of selected medical and psychiatric issues". Neuropsychiatric Disease and Treatment. 5: 61–6. doi:10.2147/ndt.s2883. PMC 2695211. PMID 19557101.
  24. ^ Kraines SH (July 1934). "Bell's mania". American Journal of Psychiatry. 91 (1): 29–40. doi:10.1176/ajp.91.1.29.
  25. ^ Truscott A (March 2008). "A knee in the neck of excited delirium". CMAJ. 178 (6): 669–70. doi:10.1503/cmaj.080210. PMC 2263095. PMID 18332375.
  26. ^ a b Wetli CV, Fishbain DA (July 1985). "Cocaine-induced psychosis and sudden death in recreational cocaine users". Journal of Forensic Sciences. 30 (3): 873–80. doi:10.1520/JFS11020J. PMID 4031813. Retrieved June 8, 2020.
  27. ^ a b Santo A (June 4, 2020). "An Officer Suggested George Floyd Had "Excited Delirium." Experts Say That's Not a Real Thing". Slate. Retrieved June 17, 2020. They note, for example, that it’s disproportionately cited in cases where black and Hispanic men die in custody.
  28. ^ Goldman R (March 2, 2007). "Excited Delirium: Police Brutality vs. Sheer Insanity". ABC News. Archived from the original on December 10, 2008. Retrieved March 13, 2007. Police and defense attorneys are squaring off over a medical condition so rare and controversial it can't be found in any medical dictionary — excited delirium. Victims share a host of symptoms and similarities. They tend to be overweight males, high on drugs, and display extremely erratic and violent behavior. But victims also share something else in common. The disorder seems to manifest itself when people are under stress, particularly when in police custody, and is often diagnosed only after the victims die.
  29. ^ Singh M (July 2, 2020). "How America's broken autopsy system can mask police violence". The Guardian.
  30. ^ Wedell K, Kelly C. "'Excited delirium' cited as factor in many fatal police restraint cases. Some say it's bogus". USA Today. Retrieved June 17, 2020. For decades critics have pointed to the fact that the term is applied almost exclusively to in-custody deaths or that otherwise involve law enforcement.
  31. ^ Koerth M (June 8, 2020). "The Two Autopsies Of George Floyd Aren't As Different As They Seem". FiveThirtyEight. Retrieved June 17, 2020. The dead people diagnosed with it tend to be young, black males who died in police custody, he said.
  32. ^ Truscott A (March 2008). "A knee in the neck of excited delirium". CMAJ. 178 (6): 669–70. doi:10.1503/cmaj.080210. PMC 2263095. PMID 18332375.
  33. ^ Paquette M (2003). Paquette M (ed.). "Excited delirium: does it exist?". Perspectives in Psychiatric Care. 39 (3): 93–4. doi:10.1111/j.1744-6163.2003.00093.x. PMID 14606228.
  34. ^ a b Costello D (April 21, 2003). "Excited delirium' as a cause of death". Los Angeles Times. Archived from the original on November 3, 2012.
  35. ^ Hall N (May 14, 2008). "Police are 'brainwashed' by Taser maker; Psychologist blames instructions". Vancouver Sun. Canwest. pp. A1. Archived from the original on May 14, 2008. Retrieved August 30, 2008.
  36. ^ Kiedrowski J (June 5, 2008). "An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police". Royal Canadian Mounted Police. Archived from the original on December 31, 2009.
  37. ^ Jauchem JR (January 2010). "Deaths in custody: are some due to electronic control devices (including TASER devices) or excited delirium?". Journal of Forensic and Legal Medicine. 17 (1): 1–7. doi:10.1016/j.jflm.2008.05.011. PMID 20083043.