July 13, 2020
A Look At Excited Delirium
By Michael D. Shaw
Any syndrome with name that initially seems so odd deserves a proper definition. We turn to a continuing education article from EMS World to get us started:
“Excited delirium syndrome (ExDS) (aka as agitated delirium) is characterized by extreme agitation and aggression in a patient with altered mental status. Patients with ExDS display violent behavior, increased pain tolerance and superhuman strength. These patients are difficult to physically restrain and continue to struggle even once restrained. Because ExDS produces hyperthermia, patients are often found naked or inappropriately clothed with hot and diaphoretic skin. EMS providers must be able to recognize ExDS and initiate treatment because the syndrome progresses to cardiac arrest in an estimated 10% of cases.”
Breaking the term down further, Stedman’s Medical Dictionary defines “Delirium” as “An altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception (illusions and hallucinations), prominent hyperactivity, agitation, and autonomic nervous system overactivity, caused by illness, medication, or toxic, structural, or metabolic disorders.”
And, “excited is a less well-defined term that is used to describe patients with uncontrollable and violent behavior.” (From this reference.) Another reference refers to “excitement” as a response to stimuli, often used specifically to denote excessive responsiveness to stimuli, particularly of an emotional nature, and often leading to impulsive activity.
The notion of “excited delirium” was first used in 1849 to describe psychiatric patients who developed continuous agitation and mania in the presence of fever, then suddenly collapsed and died. To clarify, at that time, it was called “Bell’s Mania,” for Luther Bell, who first documented it.
Emergency medical services personnel and ER doctors have been well acquainted with ExDS for decades, but its official recognition as a clinical entity is more recent. Within the past 40 years, and the proliferation of cocaine-induced incidents and related deaths, use of term was first adopted by medical examiners, who used ExDS as a diagnosis of exclusion to explain the deaths of severely agitated patients, often in police custody. In 2009, the American College of Emergency Physicians provided such official recognition.
Civil libertarians have argued that ExDS provides a convenient excuse to justify excessively brutal treatment of offenders by the police. But, this seems a bit simplistic. Ideally, such patients should be sedated on the spot, but imagine the outcry if police were to be provided with those sorts of drugs! In most real-world situations, EMS is called, but serious consequences can occur before they arrive.
Moreover, while it is pointed out that ExDS is not specifically listed in the DSM-5, or the ICD-10, both publications have other diagnoses which describe the population of patients exhibiting signs and symptoms of ExDS.
Some have tried to tie increased use of electronic control devices (aka tasers) to findings of ExDS, but this paper concluded that the symptoms associated with ExDS 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.
As noted in one of the sources cited in the above linked paper, “All aspects of the medicolegal death investigation triad—investigation (history), pathology, and laboratory results—are essential and must be evaluated in context with one another.”
However, it must also be understood that the first responders most likely to confront ExDS subjects are law enforcement officers, and their actions are based on split-second decisions. As is emphasized by the American College of Emergency Physicians…
Given the irrational and potentially violent, dangerous, and lethal behavior of an ExDS subject, any LEO interaction with a person in this situation risks significant injury or death to either the LEO or the ExDS subject who has a potentially lethal medical syndrome. This already challenging situation has the potential for intense public scrutiny coupled with the expectation of a perfect outcome. Anything less creates a situation of potential public outrage. Unfortunately, this dangerous medical situation makes perfect outcomes difficult in many circumstances.