|Other names||Excited delirium syndrome, agitated delirium|
|An example of physical restraints which may be used until chemical sedation takes effect.|
|Specialty||Emergency medicine, psychiatry|
|Symptoms||Agitation, delirium, sweating|
|Complications||Rhabdomyolysis, high blood potassium|
|Causes||Drug use, mental illness|
|Differential diagnosis||Low blood sugar, heat stroke, thyrotoxicosis, paranoid schizophrenia, bipolar disorder|
|Treatment||Sedation, cooling, intravenous fluids|
|Medication||Ketamine or midazolam and haloperidol|
|Prognosis||Risk of death < 10%|
Excited delirium (EXD), also known as agitated delirium, is a syndrome that presents with psychomotor agitation, delirium, and sweating. It may include attempts at violence, unexpected strength, and very high body temperature. Complications may include rhabdomyolysis or high blood potassium.
Definitions and symptoms
EXD has been accepted by the National Association of Medical Examiners and 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. 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."
The diagnosis was not in the 2013 Diagnostic and Statistical Manual of Mental Disorders-5 or the 1992 International Classification of Diseases.
Treatment and prognosis
Treatment initially includes medications to sedate the person such as ketamine or midazolam and haloperidol injected into a muscle. Rapid cooling may be required in those with high body temperature. Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful. The risk of death among those affected is less than 10%. If death occurs it is typically sudden and cardiac in nature.
Epidemiology and history
How frequently cases occur is unknown. Males are affected more often than females. Those who die from the condition are typically male with an average age of 36. Often law enforcement has used tasers or physical measures in these cases. A similar condition was described in the 1800s and was referred to as "Bell's mania".
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". The JFS article reported that in "five of the seven" cases they studied, deaths occurred while in police custody.
Signs and symptoms
- Aggressiveness and combativeness
- Fast heart rate
- Diaphoresis (profuse sweating)
- Incoherent speech or shouting
- Unexpected strength (typically while trying to resist restraint)
- Hyperthermia (overheating)
- Inappropriately clothed e.g. having removed garments
Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV. Alcohol withdrawal or head trauma may also contribute to the condition. A majority of fatal cases involved men.
People with excited delirium commonly have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine. Other drugs that may contribute to death are antipsychotics.
The cause is often related to long-term drug use or mental illness. Commonly involved drugs include cocaine, methamphetamine, or certain substituted cathinones. In those with mental illness, rapidly stopping medications such as antipsychotics may trigger the condition.
The pathophysiology of excited delirium is unclear, but likely involves multiple factors. These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal abnormal heart rhythms. The underlying mechanism may involve dysfunction of the dopamine system in the brain.
Key signs of excited delirium are aggression, altered mental status, and diaphoresis/hyperthermia.
Treatment initially may include ketamine or midazolam and haloperidol injected into a muscle to sedate the person. Rapid cooling may be required in those with high body temperature. Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful. One of the benefits of ketamine is its rapid onset of action.
The condition is not recognized by the American Psychiatric Association, American Medical Association or the World Health Organization. Critics of excited delirium have stated that the condition is often attributed to deaths while in the custody of law enforcement and is disproportionately applied to black and Hispanic victims. 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."
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. In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.
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. 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.
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.
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They note, for example, that it’s disproportionately cited in cases where black and Hispanic men die in custody.
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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.
- Singh, Maanvi (July 2, 2020). "How America's broken autopsy system can mask police violence". The Guardian.
- Wedell, Katie; Kelly, Cara. "'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.
- Koerth, Maggie (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.
- "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?
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