Excited Delirium

1. Excited Delirium Ohio State Parks 2006 In-Service Training

2. Sudden Custody Death Syndrome • The victims of Sudden Custody Death Syndrome (SCDS) usually have levels of identifiable foreign agents in their system • These agents trigger abnormal behavior, actions, reactions or personal conduct. • This abnormal behavior often calls for a police response.

3. Sudden Custody Death Syndrome • Original studies of these in custody deaths began back in the 1980’s in Miami with Metro-Dade police. • The studies began as an attempt by medical examiners to understand why people were dying in police custody. • There was no apparent reason for the death. So, why did they die?

4. Sudden Custody Death Syndrome • Deaths in police custody have occurred as a result of almost every level and type of force • Physical controlling a person • Aerosols • Batons • Conducted energy weapons • Handcuffing

5. Sudden Custody Death Syndrome • Studies broadened as examiners found these deaths were not just occurring with police arrests • The victims of SCDS die in ambulances, emergency rooms, trauma centers and under the immediate care of trained and highly skilled medical personnel.

6. Excited Delirium • The most reported and controversial are the deaths that occur in police custody. • Continued studies reveled behavioral similarities between cocaine psychosis victims, those under the influence of other drugs, and those with severe physiological problems. • As a result, a new term “Excited Delirium” came about.

7. Definitions • Delirium Defined: • Acute change in mental status characterized by impairment of attention. • Excited Delirium Defined: • Delirium with continuous agitation

8. Diagnostic Criteria • Diagnostic Criteria for Delirium • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. • A change in cognition such as memory deficit, disorientation, language disturbance • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate.

9. Research Findings • Excited Delirium often involved psycho-stimulant drugs • Amphetamines • amphetamine derivatives • Cocaine • Sometimes even the lack of having taken certain prescription drugs could cause a similar response behavior • i.e. lithium in the case of manic depressants

10. Research Findings • Psycho-stimulant drugs can produce a number of potentially lethal effects • Psycho-stimulant overdoses can cause • cardiovascular compromise • Seizures • hyperthermia.

11. Hyperthermia • Hyperthermia is a common result of overdoses but may also occurs in lower doses of psycho-stimulants • Psycho-stimulants induced hyperthermia may lead to rhabdomyolysis. • Rhabdomyolysis is the breakdown of muscle fibers resulting in the release of muscle fiber contents into the circulation. Some of these are toxic to the kidney and frequently result in kidney damage.

12. Excited Delirium • Symptoms / Behavioral Patterns • Signs of overheating • high temps (106-108) • seizures • profuse sweating • public disrobing • shivering • jumping into water

13. Excited Delirium • Symptoms / Behavioral Patterns (continued) • panic • paranoia • fear • hiding behind things • shouting • bizarre and aggressive behavior • self-inflicted injuries

14. Excited Delirium • Symptoms / Behavioral Patterns (continued) • irrational, incoherent speech • slurring or slowness of speech • dilated pupils • disturbances in breathing patterns • loss of consciousness

15. Excited Delirium • Symptoms / Behavioral Patterns (Continued) • unexpected physical strength • violent behavior (general) • violence towards others • violence towards objects (glass) • watch for more than one symptom

16. Positional Asphyxia • The position of the body interferes with the person’s ability to breath. • This interference with proper breathing produces an oxygen deficiency (hypoxia) in the blood • Hypoxia disturbs the body’s chemistry and can create a condition for fatal rhythm disturbance in the heart.

17. DR. Reay’s Study • Pub. 1988 - American Journal of Forensic Medical Pathology • concluded that after exercise (or violent struggles) blood oxygen levels decrease. • “Hog-tie Restraints” prevent these levels from rising again because it impairs the mechanical process of inhaling and exhaling. • Lactic Acidosis occurs and subject cannot exhale enough of the carbon dioxide that builds up.

18. DR. Thomas Neuman’s study • 1988 case - Price v. County of San Diego • Tests conducted at UCSD Medical Center • finding - blood oxygen levels do not decrease after exercise (struggle). The blood maintains enough oxygen. • hog-tie restraint impairs normal breathing to an extent but does not affect blood oxygen or carbon dioxide levels. • Methodological and logical flaws of Reay’s study were explained • Reay retracted his findings

19. Cruz v. City of Laramie, WY • U.S. Court of Appeals 10th Circuit • Holding: Hog tie on suspects with diminished capacity considered excessive force in Sec. 1983 action. • Did not reach the question as to whether all hog tie restraints were a constitutional violation per se • Court held that applying this technique when a subjects diminished capacity is apparent isunreasonable.

20. A Medical Emergency • Always keep in mind that people that exhibit symptoms and behavioral patterns suggesting excited delirium are experiencing a medical emergency • Manic depressants taking Lithium will sometimes discontinue taking their meds. These subjects often appear to be in a state of Excited Delirium and may well be.

21. The Medical Response • Early Management: • CPR and defibrillation if necessary • Sedation • Cooling • Restraints if necessary •  Increased mortality if patient is restrained (without adequate sedation).

22. Advanced Medical Care • Treatment: • Sedation • Oxygen • Cooling • Hemodialysis • Even when receiving the proper emergency medical treatment some persons suffering from Excited Delirium still die.

23. Risk Factors • Subjects at Risk for Excited Delirium • Obese • Elderly • Prior medical condition • Sickle cell trait • Asthma • Diabetes • Cardiac diseases • Intoxication • 70% of subjects resisting arrest are under the influence of alcohol or drugs.

24. In-Custody Death Prevention Guidelines • Be aware of excited delirium and other deadly medical problems. • Know when to call EMS and do not hesitate. • Do not compress the chest • Have the subject sit as soon as possible, if level of consciousness is normal

25. Activate EMS • When: • There are signs of distress (loss of consciousness, difficulty breathing, chest pain...) • Unusual agitation • Disturbed behavior • Excessive Intoxication • If the subject requests it

26. Excited Delirium - Summary • Regardless of the force option used, whenever an individual is suspected of drug intoxication, there is a risk that the drugs may cause “Excited Delirium” • “Excited Delirium” can result in potential heart or breathing problems and death.

27. Final Points • Excited Delirium is a “Medical Emergency” • BEWARE of “Sudden Tranquility” • Anticipate sudden violent acts • Try to minimize the appearance of “mishandling” suspect. • Transportation of the suspect by EMS is always preferred