After this block of instruction you should be able to: o Define excited delirium syndrome (ExDS) and risk factors o Understand the pathophysiology of excited delirium o Understand the Law Enforcement role in excited delirium syndrome

Excited delirium: A condition that manifests as a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature and superhuman strength. Lack of an accurate, uniform database to track this phenomenon.

Usually many factors lead to death and not one specific cause

One important study found that only 18 of 214 individuals identified as having ExDS died while being restrained or taken into custody. (Stratton, 2006) o Male under the age of 44 median age of 36 o Use/abuse of illicit drugs o Preexisting mental and/or cardiovascular disease o Exhibition of bizarre behavior such as: • Various stages of nudity • Incoherence and delirium • Violence/attacking or breaking glass • Running in traffic • Paranoia

 Illicit drug use is an underlying factor in ExDS cases

 Common drugs found in the ExDS person were: • Cocaine • Lysergic acid diethylamide (LSD) • Methamphetamines One study out of Ventura County, CA found that of the11 persons who died as a result of ExDS : • Three suffered from psychosis • Six were high on cocaine • One from meth • One from LSD  Autopsies often reveal severe atherosclerosis, cardiomyopathy and diabetes.

 Cardiomyopathy results from chronic cocaine and methamphetamine abuse.

 The combination of the metabolic arrest with severe cardiovascular disease makes a successful resuscitation highly unlikely.  Those suffering from psychological illness are routinely prescribed dopamine reuptake inhibitors. (DRI)

 They are used to treat depression, ADHD and even obesity.

 Much higher risk of ExDS in combination of illicit drug use due to prior use of DRIs Dopamine, the reward chemical in your brain, is blocked from being removed from your system. The result is a considerable build up of this chemical.

Heart rate, respiration and temperature control are all affected by dopamine levels with elevation resulting in tachycardia, tachypnea and hyperthermia. NOTACRIME pneumonic used to remember specific clues or behaviors we can use to identify ExDS subjects

Hyperthermia -partially clothes -naked subject -cold environments are a huge clue -an indicator of impending death

 Breaking objects within reach

 High likelihood that glass is targeted which creates a danger for blood borne pathogens

 Seems like super human strength.

 Failure of normal pain responses in their system.

 Increased metabolic activity  Bystanders could state that the subject “just went crazy!”

 Damage to their cardiovasculature and build up of dopamine in their systems was not acute

 Subject confused to time, place, purpose and perception

 Typically will have no recollection of events

 Verbal loop of “get on the ground”

 Handcuffing and hobbles will take multiple officers

 Understand some subjects will not respond to pain compliance  Most, if any conversation the person is having is incoherent

 Do not rely on information they are giving you to be accurate  Any behavior that seems out of ordinary

 Can be anything you observe from scene

 Bystanders can also be helpful for subjects history  Always advised to have EMS coming to stage code 2 if:

-dispatched to a combative or likely combative emotionally disturbed person

-call comments state any injury

-you feel that this is a true ExDS per the comments •Sudden cardiac arrest typically occurs immediately following a violent struggle

•Place the subject in the recovery position to alleviate positional asphyxia

•Once in handcuffs, get EMS on scene quickly to monitor and transport

•Sign a transport hold on these individuals

•Complete a CIC report  Assist in controlling suspect for you, your partner and EMS safety on scene

 If EMS decides to medicate suspect they could use: -Benzodiazephines like versed -Antipsychotics like haldol -Dissociative agent ketamine

 Twenty medical doctors across the United States contributed the White Paper Report on Excited Delirium Syndrome in 2010

 “beneficial use of aggressive chemical sedation as first line intervention.”

 “Law enforcement control measures should be combined with immediate sedative medical intervention to attempt to reduce the risk of death.” MPD employees shall not make any suggestions or requests regarding medical courses of action to be taken by any medical personnel. Determinations made by medical personnel regarding medical courses of action must be clearly made by medical personnel.   1. MPD employees shall provide medical personnel with any necessary information related to the subject’s observed or known conditions and behaviors, so the medical personnel can conduct a quick and accurate assessment and determine the best medical course of action.   2. MPD employees shall provide medical personnel the names of any MPD employees who provided first aid or assisted with a person’s care, so that notifications can be made to involved officers of possible exposure to any pathogens discovered through further medical examination. PROFOUND AGITATION If the patient is profoundly agitated with active physical violence to himself/herself or others evident, and usual chemical or physical restraints (section C) may not be appropriate or safely used, consider: a. Ketamine 5 mg/kg IM (If IV already established, may give 2 mg/kg IV/IO).

A.If Ketamine is administered, rapidly move the patient to the ambulance and be prepared to provide: a. Respiratory support including suctioning, oxygen, and intubation. B. Monitoring of the airway for laryngospasm (presents as stridor, abrupt cyanosis/hypoxia early in sedation period). If laryngospasm occurs perform the following in sequence until the patient is ventilating, then support as needed  NEVER go to an EDP call alone

 Always have an escape route

 Have a back up plan when taser or pain compliance fails

 If taser is used, get hands on instantly

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/#b6- wjem12_1p0077  O’Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol. 1993;14(4):289–95  https://www.webmd.com/bipolar-disorder/guide/antipsychotic- medication  http://www.fmhac.net/assets/documents/2012/presentations/krelsteinex citeddelirium.pdf  https://en.wikipedia.org/wiki/Dissociative  https://www.rxlist.com/benzodiazepines/drugs-condition.htm  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/#b10- wjem12_1p0077  https://www.jems.com/articles/print/volume-36/issue-2/patient- care/excited-delirium-strikes-witho.html  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691515/