First Response to Excited Delirium Syndrome

FIRST RESPONSE TO EXCITED DELIRIUM SYNDROME 9

First Response to Excited Delirium Syndrome

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FIRST RESPONSE TO EXCITED DELIRIUM SYNDROME 9

Abstract

Police and medical first responders increasingly contact highly agitated individuals demonstrating a cluster of symptoms associated with a little known condition called Excited Delirium Syndrome (ExDS). Although there is not yet a commonly accepted definition of ExDS, growing evidence over the last decade suggests that individuals displaying associated symptoms require immediate medical intervention because they are at high risk of sudden and unexpected death. Occasionally, death follows police use of force, even though the force may not have been sufficient to cause death or serious injury. Recent studies provide a potential explanation and template for a combined police-medical response protocol to ExDS to mitigate morbidity and resultant litigation.

FIRST RESPONSE TO EXCITED DELIRIUM SYNDROME 9

First Response to Excited Delirium Syndrome

Law enforcement officers are routinely called on to confront physically, mentally and emotionally challenging situations in which they are required to respond quickly, safely and appropriately. Perhaps one of the most challenging situations facing police today is responding to subjects suffering from a little known condition called Excited Delirium Syndrome (ExDS). It is critical for officers to recognize the symptoms of ExDS, understand the situation as a potentially drug-related medical emergency, and respond appropriately to safeguard life and property. As shown in Table 1, individuals experiencing ExDS typically present with a sudden onset of common symptoms that draw the attention of the public and law enforcement (Wetli, Mash, & Karch, 1996).

Table 1

ExDS Indicators

·  Extreme aggression or violent behavior
·  Constant or near constant physical activity
·  Unresponsiveness to directions or others’ presence
·  Attraction to glass and or mirrors
·  Nakedness/Inadequate clothing
·  Rapid breath
·  Profuse sweating
·  Incredible tolerance to pain
·  Excessive strength
·  Unintelligible or guttural noises
Note: Not all symptoms may be present, or symptoms may present as transient

ExDS is not a recent phenomenon, with reported cases tracing 150 years of subjects displaying similar symptoms and behaviors. “The behavior seen in these cases has been called ‘Bell’s Mania,’ named after Dr. Luther Bell, the primary psychiatrist at the McLane Asylum for the insane in Massachusetts. Dr. Bell was the first to describe a clinical condition that took the lives of 75% of those suffering from it.”(American College of Emergency Physicians [ACEP], 2009, p. 6). Contemporary clinicians relate Dr. Bell’s descriptions to current symptomology of ExDS.

Dr. Bell’s reported mortality rate of 75% sends a chilling message to police and medical first responders who may contact individuals experiencing ExDS. As the ACEP (2009) report indicates, clinical identification of ExDS is difficult to pinpoint due to signs and behaviors that overlap with other diseases and syndromes, such as Neuroleptic Malignant Syndrome (NMS). Though police officers are not physicians or EMS personnel with authority or expertise to diagnose medical conditions, they can be trained to be observant for symptoms associated with ExDS and to respond with established agency and medical protocols.

The ACEP formally recognized ExDS as a syndrome with its 2009 White Paper Report on Excited Delirium. Unfortunately, special interest groups and some misinformed citizens claim Excited Delirium is a term invented by police to cover up police misconduct, especially police use of force.

Medical experts, such as Dr. Mark DeBard, a professor of emergency medicine at Ohio State University, report that approximately 250 patients die each year in the United States from symptoms associated with ExDS (Hoffman, 2009). In fact, Olds (2013), reports that an ExDS-related death took place in Ohio just one decade ago. This death, and others like it, confirm that ignoring the problem does not mean that it does not exist, and doing so may prompt disastrous results, including loss of life and the subsequent aftermath: pain and suffering for the deceased’s family, costly litigation, and loss of public trust in law enforcement (Johnston, 2012). Fortunately, current medical research reveals potential explanations to the causes of ExDS and response measures for desirable outcomes.

Studies support the hypothesis that ExDS is due to a brain disorder involving the dysregulated dopamine transport function (“Excited Delirium: Education, Research & Information,” 2008). Dopamine is a key neurotransmitter in synaptic function, especially related to coherence and thermal body regulation. Dysregulated dopamine transport is often drug-related, especially with cocaine and methamphetamine use. As illustrated in Figure 1,

Cocaine blocks the dopamine transporter (DAT, red plugs in the presynaptic membrane) leading to an elevation of the neurotransmitter in the synaptic cleft. An elevation of DA activates postsynaptic receptors (blue plugs in the synaptic membrane) on receiving cells. Pathologic levels of DA in the synapse causes the paranoia, delusions and psychosis. Too much DA in the synapse causes a dysregulation in the centers of the brain that controls temperature. DA is known to be linked to the central command centers in the brain that control the heart Chaotic DA signaling in the brain. This underlies the emergence of paranoia and psychosis. (“Excited Delirium: Education, Research & Information," 2008, p.1).

In other words, dopamine is not properly absorbed and reabsorbed into the membrane during the synaptic process, thereby blocking normal synaptic function and significantly, leading to extremely elevated core body temperature - the reason why first responders often encounter unclothed ExDS victims.

Figure 1

Recent research (Hoffman, 2009) suggests a combined law enforcement/EMS protocol for handling suspected incidents of ExDS. According to Hoffman (2009), 911 operators possess the professional ability and expertise to assist law enforcement by recognizing symptomatic behavior, starting with initial calls to the 911 system. Detailed physical, mental, and emotional information associated with ExDS should be relayed to the responding officers as soon as possible, and advanced EMS personnel should be dispatched with law enforcement in order to render immediate medical aid upon restraint of the subject in question.

Physical restraint by law enforcement is the most controversial aspect of response to suspected cases of ExDS. Immediate restraint is preferred; however, experts do not agree on the most effective restraint method. Several restraint options are available, including Conducted Electrical Weapons (CEW), chemical irritant sprays and batons, as well as rapid and overwhelming physical tactics by officers. Of all the possible methods, the Multiple Officer Control Tactic (MOCT) may be the least injurious option for rapid restraint. The tactic involves 4 to 6 officers gaining control of the subject’s arms and legs through rapid and unexpected physical hand and body control measures. The goal is to restrain the subject with the minimum amount of force to reduce the likelihood of injury and negative outcome. Unfortunately, not all agencies have adequate personnel readily available to employ MOCT, necessitating the use of other tools or tactics. Regardless of method, however, speed is of the essence, and adequate personnel should be present before restraint is attempted (Johnston, 2012).

After law enforcement personnel have restrained the subject, the first-line medical treatment is chemical sedation, according to the ACEP and medical experts; however, opinions differ on the preferred drug. Dr. DeBard, the previously mentioned OSU emergency physician, recommends intravenous (IV) administration of a dissociative agent such as Ketamine for its fast-acting suppressive qualities. Other options, such as benzodiazepines (Ativan, Versed) and anti-psychotics may also be administered through intramuscular (IM) or intranasal (IN) routes (ACEP, 2009). Regardless of the chemical agent chosen, first responders should remain aware that IV administration may be difficult to achieve on an agitated subject experiencing fused body tetany (full-body muscle contraction and rigidity), which is a common symptom associated with ExDS.

Once a victim is sedated, police officers and medical personnel should avoid kneeling on patients in order to allow full expansion of the chest wall and, in turn, maximum respiratory efforts (Aber, 2012). If adequate staffing exists, individual officers should be assigned to control each arm and leg of the patient for maximum safety. Since subjects exhibiting symptoms of ExDS may present as hyper-thermic, law enforcement and medical personnel should administer ice packs or refrigerated saline solution (Aber, 2012). Finally, the stabilized subject should be transported to the nearest hospital as quickly as possible for further treatment.

Law enforcement and EMS response to suspected cases of ExDS may be frightening, and both physically and mentally challenging. First responders bear the responsibility of resolving these incidents in a safe, effective, and lawful manner. Current research suggests a calm and systematic team protocol between police and EMS personnel to mitigate negative outcomes associated with ExDS.

The consensus for responding to suspected cases of ExDS is rapid and appropriate physical control measures by law enforcement, coupled with immediate administration of IV sedatives and patient cooling through the use of ice packs and or cooling saline solutions by EMS personnel (ACEP, 2009). Immediate transport to the nearest hospital emergency room for further treatment increases the chance of patient survival. Continued research and quick actions by first responders can be life-saving to persons suffering from this dangerous and still- misunderstood syndrome.

References

Aber, D. (2012, July 1). Excited Delirium: Improving our care of the agitated patient. Paramedic Mastery. Retrieved from http://stevenkanarian.wordpress.com/2012/07/01/excited-delirium-improving-our-care-of-the-agitated-patient-2/

American College of Emergency Physicians. (2009). White paper report on excited delirium syndrome. ACEP Excited Delirium Task Force. Retrieved from http://www.fmhac.net/Assets/Documents/2012/Presentations/KrelsteinExcitedDelirium.pdf

Excited Delirium: Education, Research & Information - What is excited delirium? (2008). Retrieved from http://www.excited delirium.org/indexwhatisED2.html

Johnston, J. (2012). Stop the madness: Excited Delirium Syndrome does exist. Blue Line, 24(3), 6 - 10. Retrieved from http://www.forcescience.org/blueline.pdf

Olds, D. (2013). Excited delirium. Ohio Police Chief. 61 (1), 75-77.

Wetli, C., Mash, D., & Karch, S. (1996). Cocaine-associated agitated delirium and the neuroleptic malignant syndrome. American Journal of Emergency Medicine, 14(4), 425-428.