Understanding Excited Delirium: 4 Takeaways for Law Enforcement Officers

In 2009, the American College of Emergency Physicians officially recognized excited delirium syndrome (ExDS) as a medical condition. In a recent webinar, Dr. John Peters of the Institute for the Prevention of In-Custody Deaths, Dr. Gary Vilke from the University of California-San Diego, and Chief Ken Wallentine of the West Jordan (UT) Police Department discussed the progress in documenting the prevalence of ExDS. They also covered protocols for officer safety and proven practices that increase the subject’s chances of survival. This discussion provided several takeaways for law enforcement officers to consider when training for encounters with subjects displaying excited delirium.

1. Excited delirium is a real condition.

Excited delirium has provoked some controversy, with some police critics claiming the term was “invented” to defend the excessive use of force by police officers. In fact, excited delirium is nothing new. Descriptions of cases bearing this phenomenon date back 150 years. The American Medical Association has traced events that look much like what we call excited delirium today to what was then called Bell’s Mania. In its resolution 401, A-08, the American Medical Association’s Council on Science and Public Health stated:

Excited delirium is a widely accepted entity in forensic pathology and is cited by medical examiners to explain the sudden in-custody death of individuals who are combative and in a highly agitated state. Excited delirium is broadly defined as a state of agitation, excitability, paranoia, aggression, and apparent immunity to pain, often associated with stimulant use and certain psychiatric disorders. … Speculation about triggering factors include sudden and intense activation of the sympathetic nervous system, with hyperthermia, and/or acidosis, which could trigger life-threatening arrhythmias in susceptible individuals.

The exact pathophysiology of ExDS remains unidentified, although theories on contributing factors include dopamine transporter abnormalities, genetic susceptibility, enzyme excessor deficiency, an overdose or withdrawal state, or some other multifactorial trigger. There is no definitive, diagnostic test for ExDS, meaning law enforcement officers must use identification by clinical features.

2. ExDS presents significant risk to officers.

In a recent Canadian study, it was discovered that ExDS subjects are far more violent than drunk subjects. Additional findings include:

  • With subjects displaying probable ExDS, 89% of the time there was a struggle between that subject and officer that went to the ground.
  • 82% of subjects in a state of ExDS displayed assaultive behavior or presented a threat of grievous bodily harm or death.
  • The more the ExDS features displayed by a subject, the greater chance of assaultive behavior. This greater physical risk comes from the subject’s lack of remorse, normal fear or understanding of surroundings and rational thoughts of safety. The usual tactics to detain a subject often don’t work and the potential exists for the struggle to be elongated

Excited delirium is a widely accepted entity in forensic pathology and is cited by medical examiners to explain the sudden in-custody death of individuals who are combative and in a highly agitated state.

3. Standard compliance tactics could make things worse.

De-escalation tactics are not likely to be effective, as ExDS subjects are usually either not paying attention or are unable to follow commands. If the subject does not present imminent danger to themselves or others, officers should wait until additional personnel arrive for a tactical approach to stabilize the subject. Additionally, pain compliance techniques are not likely to be effective as ExDS subjects are often impervious to pain. Because prolonged struggle increases the chance of sudden death, officers should focus on the quickest possible restraint followed by sedation by EMS personnel. When subjects don’t respond to stimuli, officers should concentrate on restraint without using large muscle groups, which minimizes the buildup of lactic acid, decreasing the risk of potential cardiac arrest. Using repeated distraction strikes or a TASER device in drive stun mode will likely not produce much impact or benefit. Clinically, TASER device use is not likely to subdue and should  the subject experience sudden cardiac arrest during the struggle, the use of multiple energy cycles will likely come under scrutiny.

4. Officers can and must learn to recognize the signs and symptoms of ExDS.

Research points to the following characteristics that can help officers identify potential ExDS subjects:

  • Subjects are overwhelmingly male, around age 30. although with the use of synthetic drugs the age can vary drastically.
  • Subjects often have an elevated body temperature, sometimes reaching 108o Many times, subjects are found to be partially clothed or naked and this is likely an attempt to cool off.
  • Other clinical symptoms include elevated heart rate, profuse sweating, skin flushing, shaking or shivering, which are likely due to the elevated body temperature.
  • Subjects may have acute drug intoxication. There is a strong association between ExDS and cocaine, methamphetamine, PCP, and synthetic drugs. The previously referenced study showed that nearly 89% of ExDS cases were perceived to be under the influence of drugs and alcohol. It is important officers recognize behavioral signs and follow their instincts if they perceive the subject is acting different than the “usual drunk.”
  • Many subjects run into or at traffic. This strong association, especially at night, is due to headlights and windshield reflections because ExDS subjects often have an aversion to objects that are reflective in nature, although the reason is unknown.

To learn four additional takeaways when encountering excited delirium, watch our on-demand webinar: Excited Delirium: 8 Key Law Enforcement Takeaways.

Editor’s note: This post has been updated to reflect that the resolution from the American Medical Association is from the association’s Council on Science and Public Health, not the position of the AMA as a whole. 

Lexipol Team

Lexipol provides public safety and local government with solutions that combine the impact of information with the power of technology. We serve more than 2 million first responders and local government officials with policies, training, grant assistance and news and analysis.

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