11

Excited Delirium and Excited Delirium and In-custody DeathsIn-custody Deaths

Richard Barney, MD FACEPRichard Barney, MD FACEPAssistant Clinical Professor of Assistant Clinical Professor of

MedicineMedicineUW MedflightUW Medflight

EMS Medical Director- Rock CountyEMS Medical Director- Rock CountyBeloit Memorial HospitalBeloit Memorial Hospital

22

In-Custody Deaths…In-Custody Deaths…

Why do some people die following a Why do some people die following a violent confrontation with police?violent confrontation with police?

What role does the taser play, if any?What role does the taser play, if any?What role does position of the patient playWhat role does position of the patient playWhat can police officers do to prevent in-What can police officers do to prevent in-

custody deaths? custody deaths? What is EMS Role?What is EMS Role?What is the ER Role?What is the ER Role?

33

Typical ScenarioTypical Scenario

Male subject creating a disturbanceMale subject creating a disturbanceTriggers 911 callTriggers 911 callObvious to police that subject will resistObvious to police that subject will resistStruggle ensues with multiple officersStruggle ensues with multiple officers

May involve OC, Taser, choke holds, batons, May involve OC, Taser, choke holds, batons, etc.etc.

44

Typical ScenarioTypical Scenario

Physical restraints appliedPhysical restraints appliedSubject subdued in a prone position Subject subdued in a prone position Officers kneeling on subjects backOfficers kneeling on subjects backHandcuffs, ankle cuffsHandcuffs, ankle cuffsHogtying, hobble restraint Hogtying, hobble restraint

Prone vs. lateral positioning Prone vs. lateral positioning Transported in a squad car to jailTransported in a squad car to jail

55

Typical ScenarioTypical Scenario

Continued struggle against restraintsContinued struggle against restraintsSometimes damages squad carSometimes damages squad car

Apparent resolution periodApparent resolution periodSubject becomes calm or slips into Subject becomes calm or slips into

unconsciousnessunconsciousnessLabored or shallow breathingLabored or shallow breathingFollowed unexpectedly by…Followed unexpectedly by…

66

Typical ScenarioTypical Scenario

DeathDeathResuscitation efforts are futileResuscitation efforts are futileLos Angeles County EMS StudyLos Angeles County EMS Study

18 ED deaths witnessed by paramedics (all 18 ED deaths witnessed by paramedics (all were restrained)were restrained)

In 13 – rhythm documentedIn 13 – rhythm documentedVT and asystole were most commonVT and asystole were most common

No ventricular fibrillationNo ventricular fibrillation

All failed resuscitationAll failed resuscitation

Source: Am J Emerg Med; 2001:19(3), 187-191

77

Typical ScenarioTypical Scenario

The press:The press:Subject “died after being shocked with taser”Subject “died after being shocked with taser” Implies cause and effectImplies cause and effect

The Fallacy: “The Fallacy: “Post hoc ergo proptor hocPost hoc ergo proptor hoc””

88

Typical AftermathTypical Aftermath

Several weeks later – autopsy results…Several weeks later – autopsy results…Cause of DeathCause of Death

Excited deliriumExcited deliriumIllicit stimulant drug abuseIllicit stimulant drug abuseConcurrent medical problemsConcurrent medical problemsMinimal injury from police confrontationMinimal injury from police confrontation

It wasn’t the taser after allIt wasn’t the taser after allOfficers exoneratedOfficers exonerated

99

Restraints and Restraints and In-Custody DeathsIn-Custody Deaths

What roles do physical restraint, What roles do physical restraint, restraining technique and restraint position restraining technique and restraint position play in excited delirium deaths?play in excited delirium deaths?

1010

Physical RestraintsPhysical Restraints

Source: Prehosp Emerg Care, 2003:7(1); 48-55.

1111

Physical Restraint IssuesPhysical Restraint Issues

Positional AsphyxiaPositional AsphyxiaDeaths have occurred with subjects Deaths have occurred with subjects

restrained in a prone positionrestrained in a prone positionTheory: restricts breathingTheory: restricts breathingThe role of the position is unclearThe role of the position is unclearLittle data to support causalityLittle data to support causalityOther factors are the likely culpritsOther factors are the likely culprits

1212

Physical Restraint IssuesPhysical Restraint Issues

No clinically significant changes in No clinically significant changes in pulmonary function tests in healthy pulmonary function tests in healthy volunteersvolunteersAm J Forensic Med Pathol. 1998 Am J Forensic Med Pathol. 1998

Sep;19(3):201-5. Sep;19(3):201-5.

1313

Physical Restraint IssuesPhysical Restraint Issues

Restraint AsphyxiaRestraint Asphyxia Increased deaths in restrained patientsIncreased deaths in restrained patients Rat Study Rat Study

3 fold increase in cocaine-related deaths among “restrained” 3 fold increase in cocaine-related deaths among “restrained” ratsrats

Life Sci. 1994;55(19):PL379-82. Life Sci. 1994;55(19):PL379-82. Numerous studies now show restraint position not Numerous studies now show restraint position not

causative of deathcausative of death Routinely now rejected in the courtsRoutinely now rejected in the courts It isn’t the restraint that kills them, it is the Excited It isn’t the restraint that kills them, it is the Excited

Delirium.Delirium.

1414

Thomas A. Swift’s Electric Rifle Thomas A. Swift’s Electric Rifle (TASER)(TASER)

M26 Taser. Manufactured by Taser International

Source: http://www.keme.co.uk/~mack/M26.jpgSource: http://www.pointshooting.com/m26black.jpg

1515

Tasers, Tasers, in and of in and of

themselves, are not themselves, are not lethal weapons.lethal weapons.

1616

Tasers Use ElectricityTasers Use Electricity

It’s not the voltage it’s the amperage that It’s not the voltage it’s the amperage that is dangerousis dangerous

Tasers use high voltage, but very low Tasers use high voltage, but very low amperageamperageM26: 3.6 milliamps (average current)M26: 3.6 milliamps (average current)M26:1.76 joules per pulseM26:1.76 joules per pulseX26: 2.1 milliamps (average current)X26: 2.1 milliamps (average current)X26: 0.36 joules per pulseX26: 0.36 joules per pulse

X26 Taser delivers 19 pulses per secondX26 Taser delivers 19 pulses per second

1717

Taser EffectsTaser Effects

High voltage affects nervesHigh voltage affects nervesLeads to intense muscle contractionLeads to intense muscle contractionDoes not affect muscles directlyDoes not affect muscles directly

1818

Taser SafetyTaser Safety

215,000 officer have received 215,000 officer have received taser “ride” in trainingtaser “ride” in training

Over 500,000 reported taser Over 500,000 reported taser deployments to datedeployments to date

No causal effects for death foundNo causal effects for death found

1919

Academic Emer. Med. 2006Academic Emer. Med. 2006June;13(6):589-95June;13(6):589-95

After 5 second taser ride on numerous After 5 second taser ride on numerous subjects:subjects:No EKG changesNo EKG changesNo cardiac cell injuryNo cardiac cell injuryNo hyperkalemiaNo hyperkalemiaNo acidosisNo acidosis

2020

There is no scientific There is no scientific evidence to date of a evidence to date of a

cause and effect cause and effect relationship between relationship between

Tasers and in-Tasers and in-custody deaths.custody deaths.

2121

Several forensic Several forensic pathology studies pathology studies have cited excited have cited excited

delirium, not Tasers, delirium, not Tasers, as the cause of as the cause of

death.death.

2222

What is Excited Delirium?What is Excited Delirium?

An imminently life threatening medical An imminently life threatening medical emergency…emergency…

Massive release of epinephrine, Massive release of epinephrine, norepinephrine, dopamine, serotonin in norepinephrine, dopamine, serotonin in the body and brain. the body and brain.

Severe delirium and agitationSevere delirium and agitationNot a crime in progress!Not a crime in progress!

2323

The “Freight Train to Death”The “Freight Train to Death”

How police restrain or position the subject How police restrain or position the subject will not stop “the freight train to death”will not stop “the freight train to death”

The sooner the severe agitation is The sooner the severe agitation is terminated, the betterterminated, the better

This requires EMS response and transport This requires EMS response and transport to the hospital.to the hospital.

2424

What is Excited Delirium?What is Excited Delirium?

Diagnostic criteriaDiagnostic criteria Characteristic behavioral componentsCharacteristic behavioral components Metabolic AcidosisMetabolic Acidosis HyperthermiaHyperthermia Identifiable causeIdentifiable cause

Stimulant drugsStimulant drugs Psychiatric diseasePsychiatric disease Alcohol or medical problems rarely can causeAlcohol or medical problems rarely can cause

It does not explain all behavior that leads to It does not explain all behavior that leads to confrontation with policeconfrontation with police

2525

PathophysiologyPathophysiology

Central nervous system effects:Central nervous system effects:Changes in dopamine transporter and Changes in dopamine transporter and

receptorsreceptorsHigh release of other neurotransmittersHigh release of other neurotransmittersAccounts for behavioral changesAccounts for behavioral changesAccounts for hyperthermiaAccounts for hyperthermia

2626

Behavioral Components: Behavioral Components: DeliriumDelirium

Delirium:Delirium: ““Off the track”Off the track”ConfusionConfusionClouding of consciousnessClouding of consciousnessShifting attentionShifting attentionDisorientationDisorientationHallucinationsHallucinationsOnset rapid – acuteOnset rapid – acuteDuration brief – transientDuration brief – transient

2727

Behavioral Components:Behavioral Components:Excited (Agitated)Excited (Agitated)

Extreme agitation, increased activityExtreme agitation, increased activityAggravated by efforts to subdue and restrainAggravated by efforts to subdue and restrain

Not likely to comply after one or two tasers Not likely to comply after one or two tasers

Pressured speech, gruntingPressured speech, grunting

Inappropriate words and flight of ideas.Inappropriate words and flight of ideas.

2828

Behavioral Components:Behavioral Components:Excited (Agitated)Excited (Agitated)

Violent or aggressive behaviorViolent or aggressive behaviorTowards inanimate objects, especially Towards inanimate objects, especially

smashing glasssmashing glassTowards self, others or policeTowards self, others or police

Noncompliant with requests to desistNoncompliant with requests to desistSuperhuman strengthSuperhuman strength Insensitive to painInsensitive to pain

2929

Excited DeliriumExcited Delirium

Hyperthermia Hyperthermia High body temperatureHigh body temperature105 – 113 105 – 113 ooFFDrug’s effect on temperature control center in Drug’s effect on temperature control center in

brain (hypothalamus)brain (hypothalamus)Tell-tale signs:Tell-tale signs:

Profuse sweatingProfuse sweatingUndressing – partial or completeUndressing – partial or complete

3030

Excited DeliriumExcited Delirium

Hyperthermia Hyperthermia Aggravated by Aggravated by

increased activityincreased activitythe ensuing struggle the ensuing struggle warm humid weather (summertime)warm humid weather (summertime)dehydrationdehydrationcertain therapeutic medicationscertain therapeutic medications

3131

Excited DeliriumExcited Delirium

Metabolic AcidosisMetabolic AcidosisPotentially life threatening Potentially life threatening

Elevated blood potassium levelElevated blood potassium level

Factors: dehydration, increased activityFactors: dehydration, increased activitySurvivors:Survivors:

Kidney damage due to muscle breakdownKidney damage due to muscle breakdownMay require dialysisMay require dialysis

3232

Excited Delirium: Excited Delirium: The Usual SuspectsThe Usual Suspects

#1 Cause: Stimulant Drug Abuse#1 Cause: Stimulant Drug AbuseAcute intoxicationAcute intoxicationSuperimposed on chronic abuseSuperimposed on chronic abuseAcute intoxication triggers the eventAcute intoxication triggers the event

3333

Excited Delirium: Excited Delirium: The Usual SuspectsThe Usual Suspects

Underlying psychiatric diseaseUnderlying psychiatric diseaseFirst described in 1849 before cocaine was First described in 1849 before cocaine was

first extracted from cocoa leaf first extracted from cocoa leaf Mania (Bipolar Disorder)Mania (Bipolar Disorder)Psychosis (Schizophrenia)Psychosis (Schizophrenia)

Noncompliance with medications to control Noncompliance with medications to control psychosis or bipolar disorderpsychosis or bipolar disorderUnusual – #2 CauseUnusual – #2 Cause

Rare: New onset schizophreniaRare: New onset schizophrenia

3434

Stimulant DrugsStimulant Drugs

CocaineCocaineThe major offenderThe major offenderOn the rise due to “crack epidemic”On the rise due to “crack epidemic”

Toxicology studies show…Toxicology studies show…Low to moderate levels of cocaineLow to moderate levels of cocaineHigh levels of benzoylecognine (the major High levels of benzoylecognine (the major

breakdown product of cocaine)breakdown product of cocaine)Suggests recent use superimposed on Suggests recent use superimposed on

chronic abusechronic abuse

3535

Stimulant DrugsStimulant Drugs

Other known culprits include:Other known culprits include:MethamphetamineMethamphetaminePhencyclidine (PCP)Phencyclidine (PCP)LSDLSD

Cocaethylene = Cocaine + AlcoholCocaethylene = Cocaine + AlcoholToxic to the heartToxic to the heartUnknown role in excited delirium deathsUnknown role in excited delirium deaths

3636

Concurrent Health ConditionsConcurrent Health Conditions

ObesityObesityHeart DiseaseHeart Disease

Coronary artery disease Coronary artery disease CardiomegalyCardiomegalyHypertrophic cardiomyopathyHypertrophic cardiomyopathyMyocarditis Myocarditis Fibrotic heartFibrotic heart

3737

Autopsy ProofAutopsy Proof

Specialized laboratories can identify Specialized laboratories can identify changes in brain chemistry that are changes in brain chemistry that are characteristic of excited deliriumcharacteristic of excited delirium

Blood and brain tissue levels of Blood and brain tissue levels of benzoylecognine and cocainebenzoylecognine and cocaineTypical ratio 5:1Typical ratio 5:1

3838

Tasers and Tasers and Excited Delirium DeathsExcited Delirium Deaths

It’s not the TaserIt’s not the TaserMany in-custody deaths long before tasers Many in-custody deaths long before tasers

were ever usedwere ever usedDocumented in 1980s medical literatureDocumented in 1980s medical literature

Deaths of persons not in custodyDeaths of persons not in custodyFound naked in bathroomsFound naked in bathroomsWet towelsWet towelsEmpty ice cube trays scattered aboutEmpty ice cube trays scattered aboutA futile effort to cool themselvesA futile effort to cool themselves

3939

Excited delirium is Excited delirium is an imminently life-an imminently life-

threatening medical threatening medical emergency.emergency.

4040

The behavioral The behavioral features of excited features of excited

delirium include delirium include criminal acts, but…criminal acts, but…

4141

Excited delirium is Excited delirium is not a crime in not a crime in progress, and progress, and

responders must responders must recognize the recognize the

difference, before it’s difference, before it’s too late.too late.

4242

Recognizing Excited DeliriumRecognizing Excited Delirium

Agitation or Excitement = Increased Agitation or Excitement = Increased activity and intensityactivity and intensityAggressive, threatening or combative – gets Aggressive, threatening or combative – gets

worse when challenged or injuredworse when challenged or injuredAmazing feats of strengthAmazing feats of strengthPressured loud incoherent speechPressured loud incoherent speechSweating (or loss of sweating late)Sweating (or loss of sweating late)Dilated pupils/less reactive to lightDilated pupils/less reactive to lightRapid breathingRapid breathing

4343

Recognizing Excited DeliriumRecognizing Excited Delirium

Delirium = ConfusionDelirium = ConfusionDisorientedDisoriented

Person, place, time, purposePerson, place, time, purposeRapid onset over a short period of recent timeRapid onset over a short period of recent time

““He He just startedjust started acting strange” acting strange”Easily distracted/lack of focusEasily distracted/lack of focusDecreased awareness and perceptionDecreased awareness and perceptionRapid changes in emotions (laughter, anger, Rapid changes in emotions (laughter, anger,

sadness)sadness)

4444

Recognizing Excited DeliriumRecognizing Excited Delirium

Psychotic = bizarre behaviorPsychotic = bizarre behaviorThought content inappropriate for Thought content inappropriate for

circumstancescircumstancesHallucinations (visual or auditory)Hallucinations (visual or auditory)Delusions (grandeur, paranoia or reference)Delusions (grandeur, paranoia or reference)Flight of ideas/tangential thinkingFlight of ideas/tangential thinkingMakes you feel uncomfortableMakes you feel uncomfortable

4545

Bad Behavior: Other ReasonsBad Behavior: Other Reasons

Alcohol intoxication or withdrawalAlcohol intoxication or withdrawalOther drug use problemsOther drug use problems

Example: Cocaine psychosisExample: Cocaine psychosisPure psychiatric diseasePure psychiatric diseaseHead injuryHead injuryDementia (Alzheimer’s Disease)Dementia (Alzheimer’s Disease)HypoglycemiaHypoglycemiaHyperthyroidismHyperthyroidism

4646

Patients with excited Patients with excited delirium need rapid delirium need rapid aggressive medical aggressive medical

intervention.intervention.

4747

Alternative StrategyAlternative Strategy

Attempt verbal de-escalationAttempt verbal de-escalation Summon back-up quicklySummon back-up quickly Summon EMS as early as possibleSummon EMS as early as possible Use taser before a struggle ensuesUse taser before a struggle ensues Jump the subject and administer tranquillizerJump the subject and administer tranquillizer Back off and contain the subject without restraintBack off and contain the subject without restraint Once calm transport (no restraints?) Once calm transport (no restraints?) Minimize struggle and restraintsMinimize struggle and restraints Unrealistically simplified?? – Maybe!Unrealistically simplified?? – Maybe!

4848

The first goal of The first goal of therapy is to gain therapy is to gain

control of the violent control of the violent behavior.behavior.

4949

The “Ideal” DrugThe “Ideal” Drug

Rapid effective tranquilizationRapid effective tranquilizationNo repeat dosingNo repeat dosing

No significant adverse effects No significant adverse effects respiratory depressionrespiratory depressioncardiovascular depressioncardiovascular depressionneurological adverse effectsneurological adverse effects

Easy to administer (IM)Easy to administer (IM)Allows easy assessment of neurological Allows easy assessment of neurological

status on ED arrivalstatus on ED arrival

5050

In Search of The “Ideal” DrugIn Search of The “Ideal” Drug

BenzodiazepinesBenzodiazepinesNeurolepticsNeurolepticsAtypical antipsychoticsAtypical antipsychoticsKetamineKetamine

5151

BenzodiazepinesBenzodiazepines

EffectiveEffectiveBut usually require repeat dosesBut usually require repeat dosesAdverse reactions:Adverse reactions:

HypotensionHypotensionRespiratory DepressionRespiratory DepressionToo long to take effectToo long to take effectOver sedationOver sedation

5252

Neuroleptics and Neuroleptics and Atypical AntipsychoticsAtypical Antipsychotics

Rapid onset (10 – 15 minutes or less)Rapid onset (10 – 15 minutes or less) Do we have 15 minutes?? NODo we have 15 minutes?? NO

Can be very effective in a single doseCan be very effective in a single dose Prolong the QT Interval (Droperidol)Prolong the QT Interval (Droperidol) Target dopamine D2 receptorsTarget dopamine D2 receptors

May exacerbate hyperthermiaMay exacerbate hyperthermia

HALDOL or GEODONHALDOL or GEODON

5353

KetamineKetamine

Very rapid onset of action (<5 minutes)Very rapid onset of action (<5 minutes)Highly effective in a single doseHighly effective in a single doseFavorable safety profile in healthy patientsFavorable safety profile in healthy patientsPotential adverse effects:Potential adverse effects:

Adrenergic over stimulation in excited deliriumAdrenergic over stimulation in excited delirium ““Emergence reactions” in adultsEmergence reactions” in adultsDose 3-4 mg/Kg IMDose 3-4 mg/Kg IM

5454

Rapid Chemical Sedation is Rapid Chemical Sedation is Life-savingLife-saving

Get a chemical restraint drug into Get a chemical restraint drug into the patient at once.the patient at once.

Remove physical restraints when Remove physical restraints when feasiblefeasible

Never allow hobble or prone Never allow hobble or prone restraint!restraint!

5555

The second goal of The second goal of therapy is to stabilize therapy is to stabilize

the underlying the underlying pathophysiologic pathophysiologic

processes.processes.

5656

Immediate ExamImmediate Exam

Core temperatureCore temperature

Blood gasBlood gas

CBC and electrolytesCBC and electrolytes

Stat glucoseStat glucose

ToxicologyToxicology

EKGEKG

Urine for myoglobinUrine for myoglobin

CPKCPK

5757

Immediate TreatmentImmediate Treatment

Dehydration/Metabolic AcidosisDehydration/Metabolic Acidosis: : IV NS X 2 W/O Get ABG Bicarb for under 7.0IV NS X 2 W/O Get ABG Bicarb for under 7.0

HyperthermiaHyperthermia: : Cool environment, disrobe, tepid mist and Cool environment, disrobe, tepid mist and

fanning, cooling blanketsfanning, cooling blanketsHyperkalemia?:Hyperkalemia?:

Fluids, Calcium Chloride, Sodium Fluids, Calcium Chloride, Sodium Bicarbonate, Albuterol Bicarbonate, Albuterol

5858

Psychiatric HistoryPsychiatric History

DiagnosisDiagnosisOn Meds?On Meds?Has patient stopped meds?Has patient stopped meds?SchizophreniaSchizophreniaPersonality disorderPersonality disorderManic disorderManic disorder

5959

SummarySummary Excited Delirium is an imminently life Excited Delirium is an imminently life

threatening medical emergency, not a crime threatening medical emergency, not a crime in progressin progress

In-custody deaths likely related to excited In-custody deaths likely related to excited deliriumdelirium

Tasers – if used early – may help (remains Tasers – if used early – may help (remains unproven)unproven)

ALS medics can give potent tranquilizersALS medics can give potent tranquilizers Rapid aggressive medical stabilization Rapid aggressive medical stabilization

neededneeded

6060

SummarySummary

Beware of potential side effects of Beware of potential side effects of therapeutic drugstherapeutic drugs

Treat for hyperthermia, dehydration, Treat for hyperthermia, dehydration, metabolic acidosis and potential metabolic acidosis and potential hyperkalemiahyperkalemia