Excited delirium

Excited delirium (EXD), also known as agitated delirium, is a controversial syndrome that presents with 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
Other namesExcited delirium syndrome, agitated delirium
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]
CausesDrug 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 is not recognized by several professional medical organizations including the American Psychiatric Association, American Medical Association, and the World Health Organization.[4]

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.[5] 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 the 2020 publication, "excited delirium syndrome" is a "clinical diagnosis" with symptoms including delirium, psychomotor agitation, and hyperadrenergic autonomic dysfunction.[6]

The diagnosis was not in the 2013 Diagnostic and Statistical Manual of Mental Disorders-5 or the 1992 International Classification of Diseases.[1][7]

Treatment and prognosis

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.[8] The risk of death among those affected is less than 10%.[1] If death occurs it is typically sudden and cardiac in nature.[1]

Epidemiology and history

How frequently cases occur is unknown.[1] Males are affected more often than females.[9] Those who die from the condition are typically male with an average age of 36.[1] Often law enforcement has used tasers or physical measures in these cases.[1] A similar condition was described in the 1800s and was referred to as "Bell's mania".[1]

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".[10][11][1] The JFS article reported that in "five of the seven" cases they studied, deaths occurred while in police custody.[11]

Signs and symptoms

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

  • Paranoia
  • Disorientation
  • Dissociation
  • Aggressiveness and combativeness
  • Fast heart rate
  • Hallucination
  • Diaphoresis (profuse sweating)
  • Incoherent speech or shouting
  • Unexpected strength (typically while trying to resist restraint)
  • Hyperthermia (overheating)
  • Inappropriately clothed e.g. having removed garments

Cause

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.[5][16][17] Alcohol withdrawal or head trauma may also contribute to the condition.[13] Physical struggle, especially if prolonged, greatly exacerbates 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.

People with excited delirium commonly 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 drug 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

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

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

In 1849 a similar condition was described by Luther Bell as "Bell's mania".[24]

It was first described under the name "excited delirium" in 1985 as a condition relating to acute cocaine intoxication.[13][25]

The condition is not recognized by the American Psychiatric Association, American Medical Association or the World Health Organization.[26][27][28] 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.[26][29][30] 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

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.[31][32][33] In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.[33]

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.[34] 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.[35]

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.[36]

See also

References
  1. Vilke, GM; DeBard, ML; Chan, TC; Ho, JD; Dawes, DM; Hall, C; Curtis, MD; Costello, MW; Mash, DC; Coffman, SR; McMullen, MJ; Metzger, JC; Roberts, JR; Sztajnkrcer, MD; Henderson, SO; Adler, J; Czarnecki, F; Heck, J; Bozeman, WP (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. Gerold, KB; Gibbons, ME; Fisette RE, Jr; 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. 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. "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. ACEP Excited Delirium Task Force (September 10, 2009). "White Paper Report on Excited Delirium Syndrome" (PDF). American College of Emergency Physicians.
  6. Sekhon, Sandeep; Fischer, Michelle A.; Marwaha, Raman (2020). "Excited (Agitated) Delirium". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 31536280. Retrieved June 8, 2020.
  7. Vilke, Gary M.; Payne-James, J. Jason (2016). Current Practice in Forensic Medicine. John Wiley & Sons, Ltd. pp. 97–117. doi:10.1002/9781118456026.ch6. ISBN 9781118456026.
  8. Mankowitz, SL; Regenberg, P; Kaldan, J; Cole, JB (September 6, 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.
  9. 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.
  10. Truscott, Amanda (March 11, 2008). "A knee in the neck of excited delirium". Canadian Medical Association Journal (CMAJ). 178 (6): 669–670. doi:10.1503/cmaj.080210. ISSN 0820-3946. PMC 2263095. PMID 18332375. Retrieved June 8, 2020.
  11. Wetli, C. V.; Fishbain, D. A. (July 1985). "Cocaine-induced psychosis and sudden death in recreational cocaine users". Journal of Forensic Sciences (JFS). 30 (3): 873–880. ISSN 0022-1198. PMID 4031813. Retrieved June 8, 2020.
  12. Grant JR, Southall PE, Mealey J, Scott SR, Fowler DR (March 2009). "Excited delirium deaths in custody: past and present". Am J Forensic Med Pathol. 30 (1): 1–5. doi:10.1097/PAF.0b013e31818738a0. PMID 19237843.
  13. Samuel E, Williams RB, Ferrell RB (2009). "Excited delirium: Consideration of selected medical and psychiatric issues". Neuropsychiatr Dis Treat. 5: 61–6. doi:10.2147/ndt.s2883. PMC 2695211. PMID 19557101. Archived from the original on July 16, 2011.
  14. Lisa Hoffman (November 2009). "ACEP Recognizes Excited Delirium as Unique Syndrome". Emergency Medicine News. 31 (11): 4. doi:10.1097/01.EEM.0000340950.69012.8d.
  15. "Excited Delirium.org: For Law Enforcement". University of Miami. Archived from the original on July 26, 2011. Retrieved July 1, 2011.
  16. Ruth SoRelle (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.
  18. Minns AB, Clark RF (2012). "Toxicology and overdose of atypical antipsychotics". J Emerg Med. 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.
  20. Wang PS, Schneeweiss S, Setoguchi S, Patrick A, Avorn J, Mogun H, Choudhry NK, Brookhart MA (2007). "Ventricular arrhythmias and cerebrovascular events in the elderly using conventional and atypical antipsychotic medications". J Clin Psychopharmacol. 27 (6): 707–10. doi:10.1097/JCP.0b013e31815a882b. PMID 18004143.
  21. Otahbachi M, Cevik C, Bagdure S, Nugent K (June 2010). "Excited delirium, restraints, and unexpected death: a review of pathogenesis". Am J Forensic Med Pathol. 31 (2): 107–12. doi:10.1097/PAF.0b013e3181d76cdd. PMID 20190633.
  22. Vilke, Gary M.; Bozeman, William P.; Dawes, Donald M.; Demers, Gerard; Wilson, Michael P. (April 2012). "Excited delirium syndrome (ExDS): treatment options and considerations". Journal of Forensic and Legal Medicine. 19 (3): 117–121. doi:10.1016/j.jflm.2011.12.009. ISSN 1878-7487. PMID 22390995.
  23. Samuel, Edith; Williams, Robert B; Ferrell, Richard B (2009). "Excited delirium: Consideration of selected medical and psychiatric issues". Neuropsychiatric Disease and Treatment. 5: 61–66. ISSN 1176-6328. PMC 2695211. PMID 19557101.
  24. Kraines. "Bell's Mania". The American Journal of Psychiatry.
  25. Wetli CV, Fishbain DA (July 1985). "Cocaine-induced psychosis and sudden death in recreational cocaine users". J. Forensic Sci. 30 (3): 873–80. doi:10.1520/JFS11020J. PMID 4031813.
  26. Santo, Alysia (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.
  27. "Excited Delirium: Police Brutality vs. Sheer Insanity". ABC News. March 2, 2007. 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.
  28. Singh, Maanvi (July 2, 2020). "How America's broken autopsy system can mask police violence". The Guardian.
  29. 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.
  30. 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.
  31. 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.
  32. Paquette M (2003). Paquette, Mary (ed.). "Excited delirium: does it exist?". Perspect Psychiatr Care. 39 (3): 93–4. doi:10.1111/j.1744-6163.2003.00093.x. PMID 14606228.
  33. "'Excited delirium' as a cause of death" Archived 2012-11-03 at the Wayback Machine, Daniel Costello, Los Angeles Times, April 21, 2003
  34. Hall, Neil (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.
  35. "An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police" Archived December 31, 2009, at the Wayback Machine, John Kiedrowski, Royal Canadian Mounted Police, June 5, 2008
  36. 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.
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