| Licensure | Bulletins | System Entry | Forms | Education | Policy & Procedure | Links | Photo Gallery |
      Excited Delirium The dispatch call is for a disturbance of a mentally ill subject. A 40 year old male is yelling and screaming; he has smashed in several stores' windows; he is nude. When you arrive you find you cannot communicate with him. He is grossly incoherent, obviously hallucinating. He advances towards citizens who have stopped for the show. It is time to contain and control him. You have already employed a less-lethal approach to little or no effect. Law enforcement responds and six of you engage in a protracted physical encounter. You finally get him in 4 point restraints; you decide that he should remain in the prone position. While attempting to perform an initial examination, the subject still fights the restraints. Suddenly he stops struggling. You proceed to place him in the ambulance prior to a re-evaluation; at which time you realize he has also stopped breathing and has no pulse. Attempts to resuscitate him are futile. The subject is pronounced dead at the hospital. On autopsy, the coroner cannot find sufficient evidence to establish a cause of death. Over the past decade, increased attention has been paid to the sudden and seemingly inexplicable deaths of some subjects being held in police custody. In most of these cases, the force required to subdue the suspect was not sufficient to cause death. Medical authorities have typically had extreme difficulty in identifying the cause of death. It is estimated that there are between 50 and 125 in-custody deaths in the United States that correlate with excited delirium symptoms every year. Similar deaths also occur in psychiatric and geriatric care facilities. Much about excited delirium remains a mystery, although recent reports allege that it has been present since 1849. Excited delirium was originally a descriptive phrase coined by medical researchers to describe the extreme end of a continuum of drug abuse effects. Certain literature has expanded this descriptive phrase to a symptom of "life-threatening" linkage 2. A common cause of sudden death in police custody is cocaine toxicity, a phenomenon noted by Drs. Mittleman and Wetli in the late 1980s. Cocaine is an agent that stimulates both the central nervous and the cardiovascular system. Pharmacologically, cocaine constricts blood vessels, elevates the heart rate, raises blood pressure and increases body temperature. Such effects have produced lethal physiologic catastrophes in individuals without underlying preexisting anatomic disease(s). Mittleman and Wetli noted that the medical literature clearly documents cocaine-induced vasoconstriction, vasospasm and hypertension that have resulted in spontaneous intracranial hemorrhage and infarcts of the cerebrum (i.e. strokes), kidney and intestinal tracts 3. Cocaine may also be the cause of death in cardiovascular incidents in which there is no anatomic abnormality. Likewise, these effects can substantially compromise an already diseased heart or vascular system, potentially resulting in fatalities. Cocaine toxicity leading to death can exist in the drug abuser regardless of the actions taken by the police. Excited delirium causes a person's sympathetic nervous system to shift into overdrive. The sympathetic nervous system is responsible for the up or down regulation of most of the body's homeostatic functions, including the release of adrenalin, heart rate, body temperature, and pain perception. Physical restraint and substance abuse as discussed previously compounds the effects on the sympathetic nervous system. The patient was already in a medical crisis before you arrived on scene. It is likely they are near complete exhaustion, despite how the patient appears. Excited delirium is associated with a number of dangerous physical effects including: hyperthermia, changes in blood acidity, electrolyte imbalances, a breakdown of muscle cells, and cardiac arrhythmias such as ventricular fibrillation. The typical excited delirium death involves the subject slipping into a state of sudden tranquility, either during or after the struggle and restraint, followed by cardiac arrest. It is essential that law enforcement officers and medical care providers recognize the symptoms of excited delirium and sudden death so that appropriate emergency medical care is initiated early. If you are not sure if someone is exhibiting excited delirium behavior, err on the side of caution. Three groups of subjects are more prone to the sudden and unexpected death associated with excited delirium: people with a mental illness, (bipolar disorder or schizophrenia), chronic illicit stimulant (cocaine, methamphetamine) abusers and ecstasy, marijuana, or alcohol abusers, or a combination of mental illness and substance abuse. Other causes of excited delirium include infection, head trauma, and adverse reactions to medication. Most patients the medical provider will encounter with excited delirium are males between the ages of 30 and 40. It is rarely seen in females 1. The clinical presentation is the only finding that remains uniform through the subset of patients that succumb to this syndrome. The patient will typically be confused and demonstrate bizarre behavior that is described as beginning abruptly. The presentation may include visual or auditory hallucinations, distortions, signs of unusual fear and violence directed at objects. Frequently, the patients will be tearing at their clothing or already be partially or completely nude. When the first medical responders arrive on the scene they are likely to find the patient yelling and screaming, with labile emotions and a short attention span. The patient is typically extremely hyperthermic, and may initially be noted to have diaphoresis. The diaphoresis may resolve prior to arriving to the Emergency Department. An easy pneumonic to recall the signs associated with this syndrome, employed by several law enforcement agencies is P.R.I.O.R.I.T.Y.2
Many theories have been postulated to the cause of the unexpected death of the patient. One theory is related to the use of physical restraints. The patient is found to be combative and agitated and medical providers cannot approach the patient without endangering themselves. At this point Police Officers may become involved to subdue the patient. In the process of accomplishing this, the patient may become more agitated requiring further Brutane to subdue the patient. Leading to what Dr. Young et al. believes maybe a short duration of asphyxia; due to the high metabolic rate created by the catecholamine surge and inherent increase in oxygen requirement, which may be decreased temporarily during the above process. The short duration in theory may be long enough to create cardiac arrhythmias and lead to the inevitable demise of the patient 1. Cases leading to death draw a great deal of attention from the news media and the community. After all, once a person is in the hands of a trained medical provider all due care must be exercised to ensure his safety and medical well-being. A death may very well create an environment of suspicion concerning the propriety of the police/EMS actions 2. When approaching the patient one must remember that behavioral changes may be a symptom of a number of medical conditions including head injury, trauma, metabolic disorders and infectious etiologies. One must always consider, but not assume that the patient has a psychiatric disorder or is abusing a substance. The medical providers have only a short time to do a general evaluation and act on their assessment. During the response, maintain control of the scene and request law enforcement immediately if needed. Obviously, airway, breathing, and circulation are of utmost importance throughout the evaluation of the patient. Contact medical control as early as possible if restraints are needed. An order for restraints is a must. Patients will only be restrained if clinically justified. The use of restraints is only to be utilized if the patients is violent and may cause harm to themselves or others. Physical and/or chemical restraints are a last resort in caring for the emotionally disturbed patient. To safely restrain a patient, a minimum of 4 people are needed. Explain the procedure to the patient (and family) if possible. If attempts at verbally calming the patient have failed and the decision is made to use restraints, do not waste time bargaining with the patient. Remember through this process that you must remove equipment that may be used as a weapon. Avoid restraining the patient prone. Dr. Young reported in his retrospective review of Excited Delirium that 18 of his 21 deaths were restrained in a prone position 1. Do not remove restraints until released by medical personnel at the receiving hospital. Initiate transport as soon as medically possible. Realizing that a strong correlation exists between this patient population and demise during the restraint process, it is imperative that the medical provider be hypervigilant during this time. Place oxygen15 L/min via non-rebreather on the patient immediately once you have established he is able to protect his airway and is breathing spontaneously. Conduct a thorough re-examination as soon as medically possible. During this time obtain a blood glucose level test. If the blood sugar is <60mg/dl, administer oral glucose 15 grams orally or 1mg of IM glucagon if unable to establish an IV; 1 amp of IV D50 if an IV is present. If a normal blood glucose is established attempts of 2mg of Narcan IV/IM or SQ can be used. According to your protocols pharmacological therapy in adjunct with physical restraints is only indicated if medically necessary. If an IV is established, 3mg of IV Midazolam for sedation or 5mg of IM Midazolam; if attempts at IV access have been unsuccessful. Contact medical control for any further orders. Remember to look for Medic Alert Tags. Vitals and GCS should be recorded every 5 minutes. If Dextrose is administered, allow 2 minutes before administration of Narcan. Document the patients’ behavior, statements, actions and surroundings. Verbally attempt to calm and/or re-orient the patient to reality. Do not participate in a patient’s delusions or hallucinations. Excited delirium is a medical emergency that requires acute medical care. Although a rare syndrome, it will be up to the initial medical providers to recognize its presentation to ensure the safety of the crew and well being of the patient.
Reference
|
