Excited Delirium Checklist

Appendix A Excited Delirium Checklist

Excited delirium or excited delirium syndrome is the only one form of potential sudden death that law enforcement officers may encounter. Other potential causes of unexpected arrest-related deaths include, but are not limited to: sudden unexpected death in epilepsy, sickle cell sudden death, and severe heart disease.

Present? Criterion 911 Call – emergency contact for assistance 1. Critical call phrases include, ‘‘He just freaked out,’’ ‘‘just snapped,’’ ‘‘flipped out,’’ or a person is ‘‘running around naked.’’ [1] Law enforcement 2. Agitation, screaming, extreme fear response, or panic [2–6] 3. Violence, assault, or aggression towards others [6–9] 4. Suspicion of impending death. Typical comments include, ‘‘I’m dying,’’ ‘‘Please save me,’’ or ‘‘Don’t kill me’’ [10] 5. Incoherence or disorganized speech. Grunting or animal sounds [9,11] 6. Clothing removal inappropriate for ambient temperature or complete nudity [6,12–14]. 7. Disorientation or hallucinations [6,15–18] 8. Mania, paranoia, anxiety, or avoidance behavior [2,6,19–22] 9. Constant motion or hyperactivity [2,18,23–25] Capture, control, and restraint of subject 10. Extreme or ‘‘super human’’ strength [9,21] 11. High threshold of or imperviousness to pain [11,14] 12. Extreme stamina [26,11] 13. Brief quiet period before collapse likely corresponding with respiratory arrest [2,5,11,27] Emergency medical services contact and intervention 14. Presenting rhythm of PEA (pulseless electrical activity) or asystole [26,28–30]. Also documented by ‘‘No shock advised’’ with automatic external defibrillator [30]

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(continued) Present? Criterion Emergency department 15. High core body temperature [3,4,9,19,31,32] 16. Acidosis (acidic blood) [11,33,34] 17. Rhabdomyolysis (if suspect is resuscitated) [3,32,35] Law enforcement/forensic investigator death investigation 18. History of chronic stimulant abuse or mental illness [2,7,15,20,25,28,36–39]. History of violence or drug related arrests, mental health histories and treatments, and drug rehabilitation interventions, etc. 19. Damage to shiny objects such as glass, mirrors, and lights [11]. Reported behaviors may include attacking a squad car light bar or charging oncoming traffic at night. Occasionally generalized vandalism Pathologist – medical examiner investigation 20. Minor injuries from fighting against restraints (e.g. handcuffs, hobbles) 21. Positive mash (central nervous system biomarkers) test for dopamine transporter assay and heat shock protein [3,19,20,40–44] 22. Positive brain and hair toxicology screen for chronic stimulant abuse [40,45–49]. Post-incident drug levels may be low to negative Contributors: Mark Kroll, PhD; Charles Wetli, MD; Deborah Mash, PhD; Steven Karch, MD; Michael Graham, MD, Jeffrey Ho, MD. Notes: A syndrome is an aggregate of signs and symptoms that define a medical condition. Not all persons with a certain syndrome have all the same signs and symptoms. Not all cases of a syndrome result from the same cause. For example, some persons with carpal tunnel syndrome will have numbness and tingling, while others will have weakness and pain. Also, some persons with carpal tunnel syndrome will have it because of trauma, while others will have the syndrome because of pregnancy, diabetes, rheumatoid arthritis, or thyroid disease. Persons with the excited delirium syndrome will have various combinations of some of the signs and symptoms listed above. The cause (etiology) of the excited delirium syndrome in any individual may be due to one or more of a number of conditions. The most common conditions are mental illness and illegal stimulant abuse (especially cocaine and methamphetamine) [28]. Because the term ‘‘excited delirium syndrome’’ has not been widely used until recent years, many physicians do not recognize the term even though they may be very familiar with agitation and deaths due to drugs and other conditions. It is important to avoid the distraction of the various terms that have been applied to this syndrome. For example, what is now referred to as excited delirium [2–4,14,20,21,24,26–28,32–35,38,41,42,50–57] or agitated delirium [29,44,58–103] has also been called: Bell’s mania [18], acute exhaustive mania [104], acute delirious mania [18], delirium grave [18], typhoma [18], acute delirium [18], manic-depressive exhaustion [12], excited catatonia [77], lethal catatonia [105], and neuroleptic malignant syndrome [7,14,31,60,105].

References

1. Code 1069 Excited Delirium Dispatch Policy. In: Sheriff’s_Office, ed. Jacksonville, FL, 2006. 2. Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the commu- nity. CMAJ 1998;158:1603–7. Excited Delirium Checklist 435

3. Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechan- isms of cocaine toxicity. J Forensic Sci 1997;42:25–31. 4. Blaho K, Winbery S, Park L, Logan B, Karch SB, Barker LA. Cocaine metabolism in hyperthermic patients with excited delirium. J Clin Forensic Med 2000;7:71–6. 5. Stefan H. Sudden death of psychiatric patients following great excitation and exhaustion which has no actual anatomic basis. Dtsch Med Wehnschr 1934;60:1550–8. 6. Shulack N. Sudden ‘‘exhaustive’’ death in excited patients. Psychiatr Q 1944;18:3–12. 7. Kasantikul D, Kanchanatawan B. Neuroleptic malignant syndrome: a review and report of six cases. J Med Assoc Thai 2006;89:2155–60. 8. Bell L. On a form of disease resembling some advanced stages of mania and fever, but so contradistinguished from any ordinary observed or described combination of symptoms as to render it probable that it may be overlooked and hitherto unrecorded malady. Am J Insanity 1849;6:97–127. 9. Fishbain DA, Wetli CV. Cocaine intoxication, delirium, and death in a body packer. Ann Emerg Med 1981;10:531–2. 10. Karch S, Kroll M. Unpublished observations of 150 excited delirium cases, 2008. 11. Wetli C. Excited delirium. In: Chan R, ed. Sudden Deaths in Custody. Totowa: Humana Press, 2006:99–112. 12. Derby I. Manic-depressive ‘‘exhaustion’’ deaths. Pyschiatric Q 1933;7:436–49. 13. Shulack N. Sudden ‘‘exhaustive’’ death in excited patients. Psychiatr Q 1938;12:282–93. 14. Ross DL. Factors associated with excited delirium deaths in police custody. Mod Pathol 1998;11:1127–37. 15. Stagno D, Gibson C, Breitbart W. The delirium subtypes: a review of prevalence, phenom- enology, pathophysiology, and treatment response. Palliat Support Care 2004;2:171–9. 16. Ross CA, Peyser CE, Shapiro I, Folstein MF. Delirium: phenomenologic and etiologic subtypes. Int Psychogeriatr 1991;3:135–47. 17. Davidson G. Concerning the cause of death in certain cases. Am J Psychiatry 1934;91:41–9. 18. Kraines S. Bell’s mania (acute delirium). Am J Psychiatry 1934;91:29–40. 19. Mash DC, Ouyang Q, Pablo J, Basile M, Izenwasser S, Lieberman A, Perrin RJ. Cocaine abusers have an overexpression of alpha-synuclein in dopamine neurons. J Neurosci 2003;23:2564–71. 20. Mash DC, Pablo J, Ouyang Q, Hearn WL, Izenwasser S. Dopamine transport function is elevated in cocaine users. J Neurochem 2002;81:292–300. 21. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci 1985;30:873–80. 22. Anglin MD, Burke C, Perrochet B, Stamper E, Dawud-Noursi S. History of the methamphetamine problem. J Psychoactive Drugs 2000;32:137–41. 23. Schroeder U, Schroeder H, Darius J, Grecksch G, Sabel BA. Simulation of psychosis by continuous delivery of phencyclidine from controlled-release polymer implants. Behav Brain Res 1998;97:59–68. 24. Pedal I, Zimmer G, Mattern R, Mittmeyer HJ, Oehmichen M. Fatal incidences during arrest of highly agitated persons. Arch Kriminol 1999;203:1–9. 25. Fava M. Psychopharmacologic treatment of pathologic aggression. Psychiatr Clin North Am 1997;20:427–51. 26. DiMaio T, VJM D. Excited delirium syndrome cause of death and prevention. Boca Raton: Taylor & Francis, 2006. 27. Stratton SJ, Rogers C, Green K. Sudden death in individuals in hobble restraints during paramedic transport. Ann Emerg Med 1995;25:710–2. 28. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med 2001;19:187–91. 29. Park KS, Korn CS, Henderson SO. Agitated delirium and sudden death: two case reports. Prehosp Emerg Care 2001;5:214–6. 436 Excited Delirium Checklist

30. Swerdlow C, Kroll M, Williams H, Biria M, Lakkireddy D, Tchou P. Presenting rhythm in sudden custodial deaths after use of TASER1 electronic control device. Heart Rhythm 2008;5:S44. 31. Nielsen J, Bruhn AM. Atypical neuroleptic malignant syndrome caused by olanzapine. Acta Psychiatr Scand 2005;112:238–40; discussion 240. 32. Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome. Am J Forensic Med Pathol 1999;20:120–7. 33. Allam S, Noble JS. Cocaine-excited delirium and severe acidosis. Anaesthesia 2001;56:385–6. 34. Brice JH, Pirrallo RG, Racht E, Zachariah BS, Krohmer J. Management of the violent patient. Prehosp Emerg Care 2003;7:48–55. 35. Karch SB. Karch’s Pathology of Drug Abuse, CRC Press, Boca Raton, 2002:541. 36. DiMaio VJ. Forensic Pathology, CRC Press, Boca Raton, 2001:656. 37. Gray SD, Fatovich DM, McCoubrie DL, Daly FF. Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation. Med J Aust 2007;186:336–9. 38. Morrison A, Sadler D. Death of a psychiatric patient during physical restraint. Excited delirium – a case report. Med Sci Law 2001;41:46–50. 39. Pearlson GD. Psychiatric and medical syndromes associated with phencyclidine (PCP) abuse. Johns Hopkins Med J 1981;148:25–33. 40. Stephens BG, Jentzen JM, Karch S, Mash DC, Wetli CV. Criteria for the interpretation of cocaine levels in human biological samples and their relation to the cause of death. Am J Forensic Med Pathol 2004;25:1–10. 41. Mash DC, Staley JK. D3 dopamine and kappa opioid receptor alterations in human brain of cocaine-overdose victims. Ann N Y Acad Sci 1999;877:507–22. 42. Mash DC, Staley JK, Izenwasser S, Basile M, Ruttenber AJ. Serotonin transporters upregulate with chronic cocaine use. J Chem Neuroanat 2000;20:271–80. 43. Stephens BG, Jentzen JM, Karch S, Wetli CV, Mash DC. National Association of Medical Examiners position paper on the certification of cocaine-related deaths. Am J Forensic Med Pathol 2004;25:11–3. 44. Chen L, Segal DM, Moraes CT, Mash DC. Dopamine transporter mRNA in autopsy studies of chronic cocaine users. Brain Res Mol Brain Res 1999;73:181–5. 45. Berankova K, Habrdova V, Balikova M, Strejc P. Methamphetamine in hair and interpretation of forensic findings in a fatal case. Forensic Sci Int 2005;153:93–7. 46. Kimura H, Mukaida M, Mori A. Detection of stimulants in hair by laser microscopy. J Anal Toxicol 1999;23:577–80. 47. Takayama N, Tanaka S, Hayakawa K. Determination of stimulants in a single human hair sample by high-performance liquid chromatographic method with chemilumines- cence detection. Biomed Chromatogr 1997;11:25–8. 48. Kintz P, Cirimele V, Tracqui A, Mangin P. Simultaneous determination of amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine and 3,4-methylenedioxymetham- phetamine in human hair by gas chromatography-mass spectrometry. J Chromatogr B Biomed Appl 1995;670:162–6. 49. Nagai T, Kamiyama S, Nagai T. Forensic toxicologic analysis of methamphetamine and amphetamine optical isomers by high performance liquid chromatography. Z Rechtsmed 1988;101:151–9. 50. Sztajnkrycer MD, Baez AA. Cocaine, excited delirium and sudden unexpected death. Emerg Med Serv 2005;34:77–81. 51. O’Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol 1993;14:289–95. 52. Strote J, Range Hutson H. Taser use in restraint-related deaths. Prehosp Emerg Care 2006;10:447–50. 53. Paquette M. Excited delirium: does it exist? Perspect Psychiatr Care 2003;39:93–4. Excited Delirium Checklist 437

54. Gowers WR. A Manual of Diseases of the Nervous System, J&A Churchill, London, 1896. 55. Nahas GG, Burks TF, Hollister LE. Drug Abuse in the Decade of the Brain, IOS Press, Amsterdam, 1997:281. 56. Levine B. Principles of Forensic Toxicology, AACC, Washington, DC, 2003:385. 57. Karch SB. Drug Abuse Handbook, CRC Press, Boca Raton, FL, 2006:1267. 58. Mets B, Jamdar S, Landry D. The role of catecholamines in cocaine toxicity: a model for cocaine ‘‘sudden death’’. Life Sci 1996;59:2021–31. 59. Karch SB, Wetli CV. Agitated delirium versus positional asphyxia. Ann Emerg Med 1995;26:760–1. 60. Wetli CV, Mash D, Karch SB. Cocaine-associated agitated delirium and the neuroleptic malignant syndrome. Am J Emerg Med 1996;14:425–8. 61. Mirchandani HG, Rorke LB, Sekula-Perlman A, Hood IC. Cocaine-induced agitated delirium, forceful struggle, and minor head injury. A further definition of sudden death during restraint. Am J Forensic Med Pathol 1994;15:95–9. 62. Irwin P, Murray S, Bilinski A, Chern B, Stafford B. Alcohol withdrawal as an underrated cause of agitated delirium and terminal restlessness in patients with advanced malig- nancy. J Pain Symptom Manage 2005;29:104–8. 63. Morita T, Tei Y, Inoue S. Agitated terminal delirium and association with partial opioid substitution and hydration. J Palliat Med 2003;6:557–63. 64. Morita T, Tei Y, Inoue S. Impaired communication capacity and agitated delirium in the final week of terminally ill cancer patients: prevalence and identification of research focus. J Pain Symptom Manage 2003;26:827–34. 65. Vatsavayi V, Malhotra S, Franco K. Agitated delirium with posterior cerebral artery infarction. J Emerg Med 2003;24:263–6. 66. Vilke GM, Chan TC. Agitated delirium and sudden death. Prehosp Emerg Care 2002;6:259; author reply 259–60. 67. Frye MA, Coudreaut MF, Hakeman SM, Shah BG, Strouse TB, Skotzko CE. Contin- uous droperidol infusion for management of agitated delirium in an intensive care unit. Psychosomatics 1995;36:301–5. 68. Levenson JL. High-dose intravenous haloperidol for agitated delirium following lung transplantation. Psychosomatics 1995;36:66–8. 69. Sanders KM, Murray GB, Cassem NH. High-dose intravenous haloperidol for agitated delirium in a cardiac patient on intra-aortic balloon pump. J Clin Psychopharmacol 1991;11:146–7. 70. Verslegers W, De Deyn PP, Saerens J, Marien P, Appel B, Pickut BA, Lowenthal A. Slow progressive bilateral posterior artery infarction presenting as agitated delirium, compli- cated with Anton’s syndrome. Eur Neurol 1991;31:216–9. 71. Mori E, Yamadori A. Acute confusional state and acute agitated delirium. Occurrence after infarction in the right middle cerebral artery territory. Arch Neurol 1987;44:1139–43. 72. Julien J, Vital C, Vallat JM, Bourgoin B. Epilepsy and agitated delirium caused by an astrocytoma of the amygdala. Eur Neurol 1979;18:387–90. 73. Medina JL, Chokroverty S, Rubino FA. Syndrome of agitated delirium and visual impairment: a manifestation of medial temporo-occipital infarction. J Neurol Neurosurg Psychiatry 1977;40:861–4. 74. Medina JL, Rubino FA, Ross E. Agitated delirium caused by infarctions of the hippocam- pal formation and fusiform and lingual gyri: a case report. Neurology 1974;24:1181–3. 75. Horenstein S, Chamberlin W, Conomy J. Infarction of the fusiform and calcarine regions: agitated delirium and hemianopia. Trans Am Neurol Assoc 1967;92:85–9. 76. Spiller JA, Keen JC. Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care. Palliat Med 2006;20:17–23. 77. Pruett JR, Rizvi ST. A16-year-old girl with excited catatonia treated with low-dose oral Lorazepam. J Child Adolesc Psychopharmacol 2005;15:1005–10. 438 Excited Delirium Checklist

78. Kusne S, Smilack J. Transmission of rabies virus from an organ donor to four transplant recipients. Liver Transpl 2005;11:1295–7. 79. Duggal MK, Singh A, Arunabh, Lolis JD, Guzik HJ. Olanzapine-induced vasculitis. Am J Geriatr Pharmacother 2005;3:21–4. 80. Ogasawara K, Komoribayashi N, Kobayashi M, Fukuda T, Inoue T, Yamadate K, Ogawa A. Neural damage caused by cerebral hyperperfusion after arterial bypass surgery in a patient with moyamoya disease: case report. Neurosurgery 2005;56:E1380; discussion E1380. 81. Srinivasan A, Burton EC, Kuehnert MJ, Rupprecht C, Sutker WL, Ksiazek TG, Paddock CD, Guarner J, Shieh WJ, Goldsmith C, Hanlon CA, Zoretic J, Fischbach B, Niezgoda M, El-Feky WH, Orciari L, Sanchez EQ, Likos A, Klintmalm GB, Cardo D, LeDuc J, Chamberland ME, Jernigan DB, Zaki SR. Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med 2005;352:1103–11. 82. Cameron D, Bridge D, Blitz-Lindeque J. Use of sedation to relieve refractory symptoms in dying patients. S Afr Med J 2004;94:445–9. 83. Muller-Busch HC, Andres I, Jehser T. Sedation in palliative care – a critical analysis of 7 years experience. BMC Palliat Care 2003;2:2. 84. Cowan JD, Palmer TW. Practical guide to palliative sedation. Curr Oncol Rep 2002;4:242–9. 85. Cheng C, Roemer-Becuwe C, Pereira J. When midazolam fails. J Pain Symptom Manage 2002;23:256–65. 86. Morita T, Tsunoda J, Inoue S, Chihara S. Terminal sedation for existential distress. Am J Hosp Palliat Care 2000; 17:189–95. 87. Travis SS, Conway J, Daly M, Larsen P. Terminal restlessness in the nursing facility: assessment, palliation, and symptom management. Geriatr Nurs 2001;22:308–12. 88. Chiu TY, Hu WY, Lue BH, Cheng SY, Chen CY. Sedation for refractory symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage 2001;21:467–72. 89. Ogasawara K, Ogawa A, Okuguchi T, Kobayashi M, Suzuki M, Yoshimoto T. Post- operative hyperperfusion syndrome in elderly patients with chronic subdural hematoma. Surg Neurol 2000;54:155–9. 90. Dunlop RJ, Campbell CW. Cytokines and advanced cancer. J Pain Symptom Manage 2000;20:214–32. 91. Wein S. Sedation in the imminently dying patient. Oncology (Williston Park) 2000;14:585–92; discussion 592, 597–8, 601. 92. Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill patient? Support Care Cancer 1997;5:205–11. 93. Black KJ, Perlmutter JS. Septuagenarian Sydenham’s with secondary hypomania. Neuropsychiatry Neuropsychol Behav Neurol 1997;10:147–50. 94. Vaphiades MS, Celesia GG, Brigell MG. Positive spontaneous visual phenomena limited to the hemianopic field in lesions of central visual pathways. Neurology 1996;47:408–17. 95. Moyle J. The use of propofol in palliative medicine. J Pain Symptom Manage 1995;10:643–6. 96. Di Salvo TG, O’Gara PT. Torsade de pointes caused by high-dose intravenous haloperidol in cardiac patients. Clin Cardiol 1995;18:285–90. 97. Nicolai A, Lazzarino LG. Acute confusional states secondary to infarctions in the territory of the posterior cerebral artery in elderly patients. Ital J Neurol Sci 1994;15:91–6. 98. Sanders KM, Stern TA. Management of delirium associated with use of the intra-aortic balloon pump. Am J Crit Care 1993;2:371–7. 99. Fernandez F, Holmes VF, Adams F, Kavanaugh JJ. Treatment of severe, refractory agitation with a haloperidol drip. J Clin Psychiatry 1988;49:239–41. 100. Swedlow DB, Schreiner MS. Management of Reye’s syndrome. Crit Care Clin 1985;1:285–311. 101. Price J, Whitlock FA, Hall RT. The psychiatry of vertebro-basilar insufficiency with the report of a case. Psychiatr Clin (Basel) 1983;16:26–44. Excited Delirium Checklist 439

102. Steinhart MJ. Treatment of delirium – a reappraisal. Int J Psychiatry Med 1978;9:191–7. 103. Brenner WI, Lieberman AN. Acute clonidine withdrawal syndrome following open- heart operation. Ann Thorac Surg 1977;24:80–2. 104. Wendkos M. Acute Exhaustive Mania Sudden Death and Psychiatric Illness. New York: Medical & Scientific Books division of Spectrum Publications, 1979:Chapter 10. 105. Mann SC, Caroff SN, Bleier HR, Welz WK, Kling MA, Hayashida M. Lethal catatonia. Am J Psychiatry 1986;143:1374–81. Appendix B Electrocution Diagnosis Checklist

In considering the possibility that a CEW (conducted electrical weapon) may have induced VF (ventricular fibrillation), it is important to remember that: No medical, scientific, electrical, or engineering study has found that a CEW can cause cardiac capture or induce VF in a human. In addition to other studies, the latest echocardiograpahic human studies have specifically not found cardiac capture or VF during CEW discharge [1,2]. In over 500 CEW medical studies of human exposures, many of which occurred across the chest, none induced cardiac capture or VF [1-15].1 No closely monitored medical study of CEW field-use has found any case of CEW induced VF [16,17].2 In the entire history of medical, scientific, electrical, and engineering research, no study has found that the amount of electrical charge as delivered by a battery powered handheld CEW causes cardiac capture or induces VF in humans [18]. All 10 criteria below would have to be present in order to have the possibility that a suspect was electrocuted by the CEW.

Present? Not Present Criterion Rationale From law enforcement reports 1. Probe mode deployment Drive-stun mode is not able to (instead of drive-stun). induce VF even in small swine [19,20]. 2. Use of TASER1 X26TM The M26 is unable to induce CEW instead of VF even in smaller swine ADVANCED TASER while this has occurred in M26TM CEW (M26). swine with the X26 [21]. 3. Collapse within 15 s of The electrical induction of VF initiation of a probe-mode requires 2–5 s [22–26]. application.3 Collapse in VF occurs within 10 s of the VF initiation [27].

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(continued) From EMS report 4. A defibrillator shock applied Electrically induced VF is to the person within 8–10 min terminated by a of VF terminates the VF. Law defibrillation shock 99.9% enforcement defibrillator of the time [28]. may have been used. 5. Cardiac rhythm seen within Most cardiac rhythms seen 20 min of the collapse is VF. with acute or chronic drug This is demonstrated either effects or excited delirium by an external defibrillator are not VF [29–32]. announcing ‘‘shock advised’’ After 20 min of a possible VF or by a paramedic’s EKG the rhythm may deteriorate (electrocardiograph) to another type of recording. arrhythmia [33,34]. 6. Initial presenting rhythm is Asystole and PEA cannot be not asystole or PEA induced with electrical (pulseless electrical activity). stimulation. This criterion is not valid after 20 min from collapse as VF will eventually deteriorate into asystole or PEA [34]. From autopsy report 7. One probe was directly over When VF has been induced in a cardiac ventricle (main the small swine, at least one chambers of the heart). of the probes was over a ventricle [19,35]. 8. The probe directly over the VF has only been induced even cardiac ventricle penetrated in swine with a fully inserted the skin and did not simply probe [21,35–37]. penetrate or lodge in the Note: typical probe person’s clothing. penetration is around 4 mm or approximately half of the standard 9 mm barb length. 9. The penetrating probe over Webster group predicted, from the heart penetrated straight porcine studies, that VF in and was not at an angle induction would require a that would negatively affect very thin person with a full the dart-to-heart distance. 9 mm barb penetration [35]. 10. The dart tip-to-heart The most extreme distance distance is a maximum of found by the Webster group 8 mm.4 for VF induction – in swine – was 8 mm with an average of 6 mm, and a minimum of 2 mm [35]. Swine are easy to fibrillate and thus present a conservative model [38–40]. Contributors: Mark Kroll, PhD, Richard Luceri, MD; Hugh Calkins, MD, DJ Lakkireddy, MD, Jeffrey Ho, MD. Electrocution Diagnosis Checklist 443

1. There is a single anecdote of a prisoner with a pacemaker with a possible brief cardiac capture [41,42]. Some cardiac electrophysiologists feel that the internal pacemaker recording reflects cardiac capture while others feel that the recordings only show the artifact of the CEW pulses. Regardless, on careful analysis of this case, pacemaker experts have concluded that capture, if any, could only have been caused by the pacemaker lead carrying some current to the inside of the heart. Thus, this case does not provide evidence that a CEW – absent a pacemaker – could cause cardiac capture. There was no harm to the prisoner or pacemaker. 2. An oft-cited anecdote, of possible electrically induced VF was misreported with material omissions [43]. A violent subject exhibiting most of the signs of excited delirium was briefly subdued with a short CEW discharge. Parame- dics were present and found a normal pulse and respiration after the CEW discharge. After a 14-min delay, the subject collapsed and probably had an ideoventricular rhythm. After an aggressive therapy of 3 defibrillation shocks along with atropine and epinephrine, the subject finally had the VF strip shown in the published anecdote. A total of 23 min elapsed between the CEW application and the published VF strip. 3. Collapse at the end of a longer CEW application is generally due to the ‘‘quiet period’’ after an agitated (or excited) delirium struggle which necessi- tated the long CEW application. Even before VF would theoretically be induced, the rapid cardiac capture required to induce VF would have resulted in immediate loss of blood pressure and subsequent collapse [44]. This would have ended the struggle. 4. Such a dart tip-to-heart distance is only possible in a very thin person with a small BMI (body mass index). Skin-to-heart distances of 17 mm or less are rarely found in adults, especially males. Also, most law enforcement involved custody or arrest-related deaths involve males with an above-average BMI [29] and dart-to-heart distance significantly greater than 17 mm.

References

1. Ho JD, Dawes DM, Reardon RF, Lapine AL, Dolan BJ, Lundin EJ, Miner JR. Echo- cardiographic evaluation of a TASER-X26 application in the ideal human cardiac axis. Acad Emerg Med 2008. 2. DawesD, Ho J, Miner J. Echocardiographic evaluation of TASER X261 probe deployment into the chest of human volunteers. Australas Coll Emerg Med Sci Assem 2008. 3. Dawes D, Ho J, Miner J. The neuroendocrine effects of the TASER X26: A brief report. Forensic Sci Int 2009:in press. 4. Vilke GM, Sloane C, Levine S, Neuman T, Castillo E, Chan TC. Twelve-lead electrocardiogram monitoring of subjects before and after voluntary exposure to the Taser X26. Am J Emerg Med 2008;26:1–4. 5. Sloane CM, Chan TC, Levine SD, Dunford JV, Neuman T, Vilke GM. Serum troponin I measurement of subjects exposed to the Taser X-26. J Emerg Med 2008;35:29–32. 444 Electrocution Diagnosis Checklist

6. Ho JD, Dawes DM, Bultman LL, Moscati RM, Janchar J, Miner JR. Prolonged TASER1 use on exhausted humans does not worsen markers of acidosis. Am J Emerg Med 2008:in press. 7. Ho J, Lapine A, Joing S, Reardon R, Dawes D. Confirmation of respiration during trapezial conducted electrical weapon application. Acad Emerg Med 2008;15:398. 8. Ho J, Dawes D. The effect of the extended range electronic projectile (XREP) on breathing. Australian College of Emergency Medicine Winter Symposium. Newcastle, NSW, 2008. 9. Dawes DM, Ho JD, Johnson MA, Lundin E, Janchar TA, Miner JR. 15-Second conducted electrical weapon exposure does not cause core temperature elevation in non- environmentally stressed resting adults. Forensic Sci Int 2008;176:253–7. 10. Vilke GM, Sloane CM, Bouton KD, Kolkhorst FW, Levine SD, Neuman TS, Castillo EM, Chan TC. Physiological effects of a conducted electrical weapon on human subjects. Ann Emerg Med 2007;50:569–75. 11. Vilke G, Sloane C, Levine S, Neuman T, Castillo E, Chan T. Does the Taser cause electrical changes in twelve lead ECG monitoring of human subjects. J Acad Emerg Med 2007;Abstracts:257. 12. Vilke G, Sloane C, Bouton K, Levine S, Neuman T, Castillo E, Kolkhorst F, Chan T. Cardiovascular and metabolic effects of the TASER on human subjects. J Acad Emerg Med 2007;14:104. 13. Moscati R, Ho J, Dawes D, Miner J, Reardon R, Heegaard W, Janchar T, Johnson M, Bultman L. Physiologic effects of prolonged conducted electrical weapon discharge on intoxicated adults. Soc Acad Emerg Med abstract issue 2007. 14. Levine SD, Sloane CM, Chan TC, Dunford JV, Vilke GM. Cardiac monitoring of human subjects exposed to the taser. J Emerg Med 2007;33:113–7. 15. Chan T, Sloane C, Neuman T, Levine S, Castillo E, Vilke G, Bouton K, Kohokorst F. The impact of the Taser weapon on respiratory and ventilatory function in human subjects. Acad Emerg Med 2007;14:191–192. 16. Bozeman W, Winslow J, Hauda W, Graham D, Martin B, Heck J. Injury Profile of TASER1 electrical conducted energy weapons (CEWs) Ann Emerg Med 2007;50:S65. 17. Eastman AL, Metzger JC, Pepe PE, Benitez FL, Decker J, Rinnert KJ, Field CA, Friese RS. Conductive electrical devices: a prospective, population-based study of the medical safety of law enforcement use. J Trauma 2008;64:1567–72. 18. Ideker RE, Dosdall DJ. Can the direct cardiac effects of the electric pulses generated by the TASER X26 cause immediate or delayed sudden cardiac arrest in normal adults? Am J Forensic Med Pathol 2007;28:195–201. 19. Lakkireddy D, Wallick D, Verma A, Ryschon K, Kowalewski W, Wazni O, Butany J, Martin D, Tchou PJ. Cardiac effects of electrical stun guns: does position of barbs contact make a difference? Pacing Clin Electrophysiol 2008;31:398–408. 20. Valentino DJ, Walter RJ, Dennis AJ, Nagy K, Loor MM, Winners J, Bokhari F, Wiley D, Merchant A, Joseph K, Roberts R. Acute effects of MK63 stun device discharges in miniature swine. Mil Med 2008;173:167–73. 21. Nanthakumar K, Billingsley IM, Masse S, Dorian P, Cameron D, Chauhan VS, Downar E, Sevaptsidis E. Cardiac electrophysiological consequences of neuromuscular incapacitat- ing device discharges. J Am Coll Cardiol 2006;48:798–804. 22. Biegelmeier G. Effect of current passing through the human body and the electrical impedance of the human body: A guide to IEC-Report 469. VDE,-Verlag, Berlin: ETZ, 1987. 23. Biegelmeier G, Lee WR. New considerations on the threshold of ventricular fibrillation for a.c.shocks at 5060 Hz. IEE Proc. 1980;127:Pt. A: 103–110. 24. Sharma AD, Fain E, O’Neill PG, Skadsen A, Damle R, Baker J, Chauhan V, Mazuz M, Ross T, Zhang Z. Shock on T versus direct current voltage for induction of ventricular fibrillation: a randomized prospective comparison. Pacing Clin Electrophysiol 2004;27:89–94. Electrocution Diagnosis Checklist 445

25. Weismuller P, Richter P, Binner L, Grossmann G, Hemmer W, Hoher M, Kochs M, Hombach V. Direct current application: easy induction of ventricular fibrillation for the determination of the defibrillation threshold in patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol 1992;15:1137–43. 26. Frame R, Brodman R, Furman S, Kim SG, Rot J, Ferrick K, Hollinger I, Gross J, Fisher JD. Clinical evaluation of the safety of repetitive intraoperative defibrillation threshold testing. Pacing Clin Electrophysiol 1992;15:870–7. 27. Schipke JD, Heusch G, Sanii AP, Gams E, Winter J. Static filling pressure in patients during induced ventricular fibrillation. Am J Physiol Heart Circ Physiol 2003;285:H2510–5. 28. Frame R, Brodman R, Furman S, Kim SG, Roth J, Ferrick K, Hollinger I, Gross J, Fisher JD. Clinical evaluation of the safety of repetitive intraoperative defibrillation threshold testing. Pacing Clin Electrophysiol 1992;15:870–7. 29. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med 2001;19:187–91. 30. Park KS, Korn CS, Henderson SO. Agitated delirium and sudden death: two case reports. Prehosp Emerg Care 2001;5:214–6. 31. DiMaio T, VJM D. Excited Delirium Syndrome Cause of Death and Prevention. Boca Raton: Taylor & Francis, 2006. 32. Swerdlow C, Kroll M, Williams H, Biria M, Lakkireddy D, Tchou P. Presenting rhythm in sudden custodial deaths after use of TASER1 electronic control device. Heart Rhythm 2008;5:S44. 33. Allison JS, Qin H, Dosdall DJ, Huang J, Newton JC, Allred JD, Smith WM, Ideker RE. The transmural activation sequence in porcine and canine left ventricle is markedly different during long-duration ventricular fibrillation. J Cardiovasc Electrophysiol 2007;18:1306–12. 34. Veltmann C, Borggrefe M, Schimpf R, Wolpert C. Fatal inappropriate ICD shock. J Cardiovasc Electrophysiol 2007;18:326–8. 35. Wu J, Sun H, O’Rourke A, Huebner S, Rahko P, Will J, Webster J. Taser blunt dart-to- heart distance causing ventricular fibrillation in pigs. IEEE Trans Biomed Eng 2009:in press. 36. Walter RJ, Dennis AJ, Valentino DJ, Margeta B, Nagy KK, Bokhari F, Wiley DE, Joseph KT, Roberts RR. TASER X26 discharges in swine produce potentially fatal ventricular arrhythmias. Acad Emerg Med 2008;15:66–73. 37. Wu J, Sun H, O’Rourke A, Huebner S, Rahko P, Will J, Webster J. Taser dart-to-heart distance that causes ventricular fibrillation in pigs. IEEE Trans Biomed Eng, 2007;54:503–8. 38. Dalziel CF, Lee WR. Reevaluation of lethal electric currents. IEEE Trans Ind Gen Appl 1968;IGA-4:467–6. 39. Kroll MW, Calkins H, Luceri RM, Graham M, Heegaard W. Sensitive swine and TASER electronic control devices. Acad Emerg Med 2008;15:695–6. 40. Pak HN, Kim YH, Lim HE, Chou CC, Miyauchi Y, Fang YH, Sun K, Hwang C, Chen PS. Role of the posterior papillary muscle and purkinje potentials in the mechanism of ventricular fibrillation in open chest dogs and swine: effects of catheter ablation. J Cardiovasc Electrophysiol 2006;17:777–83. 41. Cao M, Shinbane JS, Gillberg JM, Saxon LA. Taser-induced rapid ventricular myocardial capture demonstrated by pacemaker intracardiac electrograms. J Cardiovasc Elec- trophysiol 2007;18:876–9. 42. Kroll M, Luceri RM, Calkins H. A very interesting case study involving a TASER conducted electrical weapon (CEW) used on a patient with a pacemaker. J Cardiovasc Electrophysiol 2007;18:E29–30; author reply E31. 43. Kim PJ, Franklin WH. Ventricular fibrillation after stun-gun discharge. N Engl J Med 2005;353:958–9. 44. Swerdlow CD, Olson WH, O’Connor ME, Gallik DM, Malkin RA, Laks M. Cardiovas- cular collapse caused by electrocardiographically silent 60-Hz intracardiac leakage current. Implications for electrical safety. Circulation 1999;99:2559–64. Index

A Amnesty International, 262, 290, 304 Abdominal musculature, 168 Amphetamines, 306–7, 330, 366, 371 Abrasions, 34, 259, 264, 268, 276, 348, abuse of, 303 382, 385 Anatomical composition of human Accountability sanctions, 391–2 body, 197 administrative accountability, 392 Anesthesia, 89, 92, 102, 112, 206, civil accountability, 391 208, 232 criminal sanctions, 391 Angel dust, see phencyclidine, 1, 306, 331 AC-DC war, 17 Angrist, B. M., 366 Acid-base Anisotropic skeletal muscle, 73–4, 81 balancing of the respiratory system, Anodic current, 58 175, 177 Anorexic model, 67, 71 homeostasis, 169 ANOVA, 296 Acidosis, 85, 104, 106, 115, 143, 146–8, 171, Antemortem (hospital) specimens, 384 175, 182, 184, 221, 223, 311, 322, Anterolateral thoracotomy, 96 333, 359–60, 417 Anterolateral thorax, 87 ACLU, see American Civil Liberties Union Anticonvulsant prophylaxis, 208 Acoustic hailing devices, 45 Antipsychotic drugs, 303, 332–3 Adenosine triphosphate (ATP), 170 Arcing, 51–2, 61, 284–5 Adrenaline, see epinephrine, 212, 216 ARDs, see Arrest-related deaths Adrenals, 180, 334–6, 353–6 Areas of confusion, 291–4 Adrenoceptors, 335, 353 autopsy analysis, 293 Aerobic metabolism, 169, 171 drug dysynergies, 293 Airburst non-lethal munition (ANLM), 45 effects of electrical current on Alcohol breathing, 293 intoxication, 115, 220–1 electrocution, 291 physiology, 219–20 long duration shocks, 291–2 specific studies, 221 Arrest-related deaths, 183, 262, 290–1, 294, withdrawal syndrome, 220 296, 301, 328 Alcoholism, 348–9, 357 Arrhythmia, see Cardiac arrhythmia Alpert, Geoffrey P., 27, 257, 259–60 Arrhythmogenic properties, 216 Alpha-amylase levels, 182 Arrhythmogenicity, 90, 329 Alveolar dead space, 168–9 Arterial chemoreceptors, 170 AMA billing code, 361 Arteriolar dilatation, 171 American Civil Liberties Union, 261–2, Artificial heart program, 11 276, 290 Arylcyclohexylamine compounds, 331 American Medical Association (AMA), Asystole, 121, 145, 291, 293, 310, 321–2, 347, 360–1 357, 382 American Psychological Association, 418 Atherosclerotic plaque, 120

447 448 Index

Atrial naturetic factor, 316 Brain Atrioventricular dyssynchrony, 95, 154 abnormalities, 322 Auscultation, 89 atrophy, 220 Automatic external defibrillator (AED), 87, Brandishing, 284–5, 392–4 382, 386, 408 Brave, Michael A., 389 Autopsy, 290–1, 293–4, 301, 304, 307–8, 310, Brewer, James E., 283 319, 347–9, 369, 375, 380–1, 383–6, Broken bones or fractures, 268 408, 421, 427–8 Bruises, 34, 259, 264, 268, 276, 382 checklist, 382–3 Bucking, 349–50 error, 295 Buprenorphine, 102 Axon, 18, 58, 66, 187, 190, 357 Bureau of Alcohol, Tobacco, and Firearms (BATF), 19–20

B BandAid, 29 C Baron-Esquivias, 183 Cable theory, 190 Barotrauma, 196 Calton, R., 225, 232 Baseline blood testing, 221 Cambell, A., 260 Baton, 3, 211, 242, 259, 264–5, 268, 290, CaMKII (calmodulin kinase II), 316, 318 367, 381 Campbell, D. T., 422 Baxter syringe pump, 102 Canines and suspect injury, 276 Behavioral abnormalities, 287 Canines, 260, 273–4, 276–7 Bell, L. V., 331, 333–4, 347, 367 Cao, M., 224, 227 Bell’s Mania, 3, 331, 347–8, 360 Capacitance-stepped discharges, 87 Benzoylecgonine, 114, 329, 336 Capture zone of the darts, 53 Berenbom, Loren, 223 Carbon dioxide, hydration of, 169 Berk, R. A., 260 Cardiac abnormalities, 115, 134, 308 Bias and Causation theory, 427–8 rhythm abnormalities, 136, 145 Biegelmeier, G., 292 Cardiac arrest and resuscitation, 109 Bigeleisen, P., 171 Cardiac arrhythmia, 69, 119–21, 123, 125, Binary logistic regression, 266, 268–9 127–8, 133–4, 147, 165, 171, 179, Binder, A., 24 197, 216, 223, 233, 328–9, 335–7, Bingham, Greg, 235 354–5, 357, 408, 424 Biochemical brain markers, 365–77 Cardiac capture, 77, 95, 119, 121, 153, Biomarker research, 145–9 160–1, 216 creatine phosphokinase, 148 safety margins for, 78 lactate, 147 Cardiac contractility, 171 myoglobin, 148 Cardiac dysfunction, 143, 303 potassium, 146 Cardiac dysrhythmia, 95, 110, 114, 116, 137, troponin I, 146 243, 302, 307, 310 Biomarkers, 144–6, 149–50, 365, 374 Cardiac electrophysiologists, 291, 304, blood serum, 144 315, 408 Biopolymers, 196 Cardiac excitability thresholds, 79 Bipolar recording catheters, 92 Cardiac hypertrophy, 320, 337 Birmingham eye trauma terminology system Cardiac implantable devices, (BETTS), 203–4 see Pacemakers (PM) Bittner, E., 24 Cardiac irritability, 138 Bizarre behavior, 3, 6, 164, 302, 366–7 Cardiac myocyte excitation threshold, 77, 79 Blair, H. A., 123, 125 Cardiac tissue alteration, 232 Body mass index, 75, 294, 319, 419 Cardiac troponin levels, 116 Bonferroni adjustment, 90 Cardiac vulnerability, 212, 329 Boo factor, 425 Cardiomegaly, 386 Bootstrap technique, 285 Cardiomyocyte endoplasmic reticulum, 316 Index 449

Cardiomyopathy, 120, 220, 223–4, 316, 319, psychosis, 24, 366 356, 380 vasoconstrictor actions of, 329 Cardiopulmonary arrest, 309, 332–3, 347, Cohen, J., 420 349, 386 Cohen’s rule, 420 Cardiopulmonary resuscitation (CPR), 301, Cold pressor tests, 183 308, 311, 332, 350, 358, 381, 386 Cole, J. S., 18 Cardiovascular Common medical conditions associated with collapse, 179, 220 sudden death, 302 disturbances, 96 Concentric hypertrophy, 318 physiology, 115 Confidence level, 417–8 system, 137, 327, 333, 337, 348, 353 Conflict resolution, 31, 35 Castle doctrine, 389, 393 Congenital heart disease, 120 Catecholamine Conner, G. J., 27 theory, 321 Connexins, 187 toxicity, 337 Consumer Public Safety Commission Catecholamines, 321, 327, 329–30, 335–7, (CPSC), 19–20 352–3, 355–7, 428 Cook, T. D., 422 Cathodic current flow, 58 Corneal abrasion, 305 Causation theories, 421 Corneal injury, 202 Cause-and-effect relationship, 423 Coronary artery disease, 120, 223, 307, 315, Cellular damage, 144, 148–50 320, 360 Cellular destruction, 143, 146 Coronary flow reserve (CFR), 319 Central Intelligence Agency (CIA), 41 Correlation coefficient, 423 Central nervous system (CNS), 2, 203, Creatine phosphokinase (CPK), 306–29, 356, 367, 384 103, 148, 165, Chan, H., 60 Cruel and unusual punishment standard, Chan, T. C., 109, 276, 351–2 397, 399–400 Cheek, E. R., 193–4 Crush injuries, 149, 165 Chehade, M., 204–5 CSI effect, 413–4 Chemical fingerprint, 343 CT scan, 64, 208 Chemical irritant spray, 3, 5 Cuenca, Peter J., 41 Chen, S. L., 205 Current procedural terminology Cheng, Y., 192–3 (CPT), 360 Chilbert, M., 291 Curtis, H. J., 18 Choking, 404 Curtis, M., 425 Chorioretinal adhesion, 205 Custodial death data, 135 Chronic catecholamine, 333 Cyanoacrylate adhesive, 102 Chronic enlargement of the heart, 307 Civilian model, 29 Civilian riots, 42 D Clinical autopsy accuracy, 291 Dalziel, C. F., 12, 18–19 Cloud, Samuel, 165 Dart-to-heart distance, 96–101, 106, 114 Cocaine effect of, 96 abuse of, 303 measuring, 161–2 delirium, 367–8 Daubert Trilogy, 410–4 effects of, 90, 110, 114, 216, 321, 366, Davis, K. C., 24 369, 373 Dawes, D. M., 116, 167, 172, 179, 293 -induced paranoia, 366–7 Deadly force, 3, 5, 8, 24–6, 42, 44–5, 238, 258, intoxication, 254, 293, 332, 373 264–5, 269–71, 276 death due to, 254, 332, 369, 373 Deale, O. C., 81 psychiatric symptoms of, 366 Death investigation, 338–40, mechanism of action, 328 342, 380 metabolites, 306 Deductive reasoning, 415 450 Index

Defibrillation, 78, 81, 87, 98–9, 119, 121, 123, Echocardiographic 128, 188, 190, 223, 228, 232, 291, data, 106, 156 293–4, 307, 310, 321 effects, 153–62 absence of, 85 monitoring, 153–4, 156, 159–61 Defibrillator, 78, 87, 98, 228, 232, 382, 386 Echocardiography (echo), 89, 95, 99, 106, Dehydration, 309–10, 333 114, 153–4, 156, 160–1 Dementia, 63, 220 Ecstasy, 407, 424 Dennis, A. J., 94–5, 137, 153 Ectopic heartbeat, 121–3 Depolarization, 58, 187, 189–90, 192–3, 212, Edison, Thomas, 17 316–8, 320 Efimov, I. R., 187 Depolarization-repolarization process, 316 Einziger, P. D., 196 Detention operations, 41 Elective replacement indicator, Di Maio, T. G., 304, 347 223, 228, 232 Di Maio, V. J. M., 304, 347 Electric rifle, 11 Diaphragm paralysis, 176–7 Electric whaling apparatus, 19 Diastolic dysfunction, 308 Electrical pulse incapacitation, 408, 424, 427 Diastolic potential (DP), 192 Electrocardiogram (EKG), 16, 92, 106, 116, Digitorum communis muscle, 60 135, 179, 183, 223, 319 Dimsdale, J. E., 355 Electrocardiographic Ding, J., 60 effect, 133–41 Discoloration of the dura, 207 monitoring, 115 Disney World, 31 Electrocution, 6, 17, 143, 145, 165, 291, Doerner, W. G., 261 293, 302 Dopamine Electrode conducting gel, 136 receptors, 336–7, 369, 372 Electromagnetic interference, 223–4 reuptake transporters (DATs), 328–9, Electromagnetism, 15 356 Electrometer, 14 transporter, 336, 357, 368–71, 374 Electro-muscular incapacitation, 63 Dopaminergic agonists, 367 Electron microscopy, 188 Dopaminergic transmission, 371 Electrophysiologic catheter, 212 Dosdall, D. J., 119, 122–3, 125, 127 Electrophysiological abnormalities, 120 Double-barrel microelectrode, 190 Electrophysiological inhomogeneities, 94 Dragging, 404 Electrophysiology, 15–16, 18 Drive-stun mode, 2, 7, 33–6, 67, 69, 72, 75, Electroporation 176, 284, 293–4, 399–400, 402, 404 assessment, 190–3, 196 Drug of cardiac and nerve cells, 187–97 induced psychosis, 408, 424 detection of, 189 disorders, differential diagnosis, –induced ectopic activity, 190 365–7 of lipid bilayer, 188 influence of, 244, 248, 255, 393 Emergency Medical Services (EMS), 240, intoxication, 149, 183, 184, 294, 365, 380, 360, 381, 408 408, 424 Emergency Service Unit, 244, 246–50, 254–5 screening, 342 Emergency thoracotomy, 137 toxicity, 303, 310 Emotionally disturbed person (EDPs), 241, Du Boise, Reymond Emil, 15–16 244, 249, 254 Dunham, R. G., 27, 259–60 Endocardium, 110 Dural perforation, 206–7 Endophthalmitis, 206 Dysrhythmia, see Cardiac dysrhythmia Endoplasmic reticulum, 165, 316 Endothelial dysfunction, 353, 355 Ends and bends stimulation, 54 E End-tidal gases, 169 Eccentric hypertrophy, 316 Enlargement and scarring (fibrosis) of the Echo images, 106, 154–5 heart, 307 Index 451

Epicardial FN303 Less Lethal Launcher, 46 polarizations, 192 Food and Drug Administration (FDA), surface, 75, 85, 89, 224 20, 82 Epicardium, 75, 110, 189, 192 Force matrix, 27 Epidemiologic-engineering report, 12 Force-related injuries, 258–63 Epinephrine, see adrenaline, 92–4, 111, impact of nonlethal weapons, 260–1 137–8, 181–3, 212, 223, 309, 320, OC spray, 261–2 329, 334–7, 352–5 officer injury, 260 acute effects, 92–4 suspect injury, 259–61 effects of, 306 Functional residual capacity, 168 infusion, 93 Fundamental law of electrostimulation, ERI, see Elective replacement indicator 123–4, 126, 128 Erythroxylon coca, 328 Fyfe, J., 260 Ethanol addiction, 220 intoxication, 219 G Ethidium bromide (EB), 189, 194 Galbraith, J. A., 190 Ethnographic studies, 415 Gallant, P. E., 190 Evans, Michael A., 327 Galvanic stimulation, 13 Excitation thresholds, 66 Galvanometer, 16–17 Excited delirium syndrome (EDS), 121, 133, Gap junctions, 187, 195 184, 302, 311, 327–8, 331–7, Garner, J. H., 24, 28 347–61, 365, 368, 371 Gas chromatography, 343 cause of death in, 352–60 Geddes, L. A., 124–5 polymorphism, 354 Gehl, J., 66 postexercise peril, 354–7 General accountability themes, 390–1 hypokalemia and sudden cardiac Generalized activating function theory, 190 death, 335 Generalized ordered logit models mechanism of death, 334 (GOLM), 269 Expiration, 168 Giants of Electricity and Bioelectricity, Extracardiac electrical activity, 232 12–16 Eye Ampere, Andre-Marie, 14 adnexal anatomy, 201–3 Benjamin Franklin, 13 anterior chamber, 202 Coulomb, Lt. Charles Augustin, 14 posterior chamber, 202 Galvani, Luigi, 12–13 injuries by conductive electrical weapons, Oersted, Hans Christian, 14 203–6 von Guericke, 12 trauma, 203 Global war on terrorism, 41 Glutamatergic alteration, 331 Goldman, D. E., 188 F Green fluorescent protein (GFP), 194 Fallacies, 420–1 Grill, W. M., 56 Faraday, Michael, 15 Gulf war, 45 Fast, V. G., 192–4 Gumbel-Gompertz model, 289 Fatal arrhythmia, 134, 328, 337, 356–7 Gunn, Joshua, 327 Federal Rules of Evidence, 412 Gunpowder-propelled dart electrodes, 19 Fedorov, V. V., 187 Gunshot wounds, 268 Felony murder rule, 422–3 Ferris, L. P., 12, 18 Finite element modeling (FEM), 65–7, H 69–73, 75, 77–8, 79, 81 Haegeli, L. M., 226, 232 Fishbain, D. A., 306, 332 Hallucinations, 220, 327, 330–1, 333, 337, Flashlight, 5, 17, 259–60, 403 347, 358, 366 452 Index

Han, D., 183 Hypothalamus-pituitary-adrenal (HPA), Hands-on tactics, 258, 260–3, 272–3, 275 181–2 weapons for, 275 Hypoventilation, 169, 171, 175, 351 Hard empty hand control, 264–6, Hypovolemia, 164 268, 270–1 Hypoxemia, 167, 171, 175, 177 Hard-hand tactics, 272–5 Harrison Narcotics Act, 328 Harrison, R. L., 194 I Head injuries, 206–8 Ideker, R. E., 119, 122–3, 125, 127 Heart dart, 96–8, 113–4 Illegal drugs or excited delirium Heart failure, 120, 307–8, 354 behavior, 233 Heath shock proteins and hyperthermia, Illegal stimulant intoxication, 211–6 373–4 Immediate-response situations, 4 Hemidiaphragm, 170, 293 Immobilization, 183 Hemodynamic effects, 95 Implantable cardiac devices, 223–34 Hemodynamic stability of the animals, 88 Implantable cardioverter defibrillators Hemoglobin electrophoresis, 384 (ICDs), 223–4, 228, 232–3, 291 Hemorrhage, 183, 205, 207, 302, 348, 350, Implantable defibrillators, 78 380, 386 Improved flash bang grenade (IFBG), Henych, Mark, 23 45–6 Hepatosplenomegaly, 386 Incoherent shouting, 327, 333 HERG, 315, 318, 320 In-custody death, 1, 6, 24, 30, 75, 133, 165, High-frequency sinusoidal components, 60 167, 179, 182, 184, 211, 257, 276, High mobility multipurpose wheeled vehicle 301–11, 383 (HMMWV), 46–8 factors associated with sudden, 304 Hispanic subject autopsies, 295 Individual serviceman non-lethal system Ho, J. D., 133, 135, 139, 143, 219, 419 (ISNLS), 45–6 Hogtying, method of, 351, 419 Inductive reasoning, 415 Holden, S. J., 85 Inhomogeneities, 94 Human stress response, 180 Injury reduction effects, 275 Human volunteers, 81, 111–2, 114–6, 134–5, Injury severity index, 264 156, 160, 212, 221, 223 Inspiration, 167–9 Humanitarian assistance, 41 Intercostal muscles, 168 Hutson, H. R., 304 Intermediate weapons, 3, 264, 267, 275 Hypercarbia, 167, 171, 177 Internal injuries, 264, 268 Hyperexertion, 360 Internal Review Board (IRB), 418 Hyperkalemia, 85, 143, 146–7, 149, 164–5, International Association of Chiefs of Police 171, 336, 355–6 (IACP), 242, 395 Hyperpolarization response, 192–3 International classification of diseases, 361 Hypersympathetic state, 90 International Electrotechnical Commission Hypertension, 220, 307, 316, 318, 320, 335 (IEC), 291 Hyperthermia, 182, 184, 196, 309–10, Intracellular electrolytes, 144 327, 333, 336, 360, 365, 367–8, Intramuscular ketamine, 88, 92 372–4, 382 Irreversible electroporation, 66, 71–3, 197 Hypertrophy Ischemic cardiomyopathy, 224 cardiac, 320, 337 Isotropic conductive gel, 74 concentric, 318 eccentric, 316 myocardial, 316, 318–20 J ventricular, 120, 319 Jauchem, J., 94, 102–5, 113, 172 Hypoglycemia, 183 Joint locks, 44, 260, 264 Hypothalamic receptors, 374 Joint non-lethal warning munitions Hypothalamus stimulation, 334 (JNLWMs), 45–6 Index 453

K Marijuana, 331, 407 Kalamazoo Gazette, 242 Marinaro, Jonathan L., 201 Kaminski, R. J., 257 Mash, D. C., 365, 370 Karch, S. B., 293, 315 Mass spectrometry (MS), 343–4 Ketamine, 94, 306–7 Mass sympathetic discharge, 334–5 Kicking, 43, 260, 349, 402, 404 Mathis, Jason, 257 Kleber, H. D., 367, 372 Maximal voluntary ventilation Klinger, D. A., 31 (MVV), 352 Knowledge acquisition, 413 Maximum safe multiple (maxSM), 89–90 Koller’s discovery, 328 Maxwell’s equations, 18 Koslow, M., 56 Miami-Dade Police Department Kostecki, Geran, 187 (MDPD), 267 Kosten, T. R., 367, 372 models, 268–9 Kriger, M. Scott, 327 results, 272 Kroll, M. W., 179, 283 Meese, E., 11 Membrane depolarization, 94 L electroporation, 191, 194–5 Lacerations, 264, 268 Mental illness, signs of, 247 Lactate dehydrogenase (LDH), 103, 170 Mental retardation, 348 Lactic acidosis, 181 Mesloh, C., 23 Lakkireddy, D., 88–9, 91, 114, 223, 228–31 Metabolic, see acidosis Lapique, L., 123 acidosis, 104, 164, 170–1, 309–10, 427 Laser painting, 285 lactate levels, 116 Laser pointing, 284 physiology, 115 Lateral vascular neck restraint, 379, 386 Methamphetamine, 2–4, 149, 184, 212, 216, Lauer, Andreas K., 201 315, 318, 322, 327, 329–30, 332–7, Law enforcement agencies, 3, 24, 26, 29–30, 342, 344, 348, 353–4, 356–7, 361, 63, 235, 245, 257–8, 261–3, 268, 365, 367, 369, 387, 407–8, 424 277, 283, 287, 290, 296 Meyer, G., 1, 243, 259 Law enforcement model, 29 Michalewicz, B. A., 352 Law enforcement tools, 5 Microscopic remodeling, 316 Lee, W. R., 292 Midazolam, 311 Lens zonules, 202 Mineralocorticoids, 181 Lerman, B. B., 81 Minitheories, 416 Less-than-lethal force, 24, 29 Mizrahi, J., 196 Levine, S. D., 135, 139 MK19 launcher, 46 Lewman, L. V., 351 M-mode tracing, 156–9 Life-threatening injuries, 45 Monoamine oxidase (MAO), 330 Ligature restraint, 379 Monophasic wave, 57 Liquid chromatography, 344 Monster, A. W., 60 Liver failure, 220 Morabito, E. V., 261 Livshitz, L. M., 187, 196–7 Mortality risk, 262 Logistic regression, 258, 264, 266, 268–9, 272 Moscati, R., 165, 219 Motor nerve, 18, 54, 56, 63, 65–6 activation, 65 M MRI scan, 64 McDaniel, W. C., 86, 88, 113, 119, 128, 223 Multinomial logit models, 269 Magic jar, 13 Multiple hits theory, 320–2 McIntyre, C. C., 56 Multiple iterations, 36 McManus, John G., 41 Muscle impedance matching gel, 97 Magnitude of error, 418 Muscle recovery period, 85 Manic-depressive exhaustion, 360 Myocardial 454 Index

Myocardial (cont.) OC spray, 44–5, 182, 258, 261–4, 267, capture, 90, 223–4, 232 275–7, 290 damage, 182 See also Pepper spray depolarization, 316 Ochi, R., 194 dysfunction, 120–1 Oersted, 14 hypertrophy, 316–20 Officer Injuries, 287 infarction, 120, 146, 216, 302, 315, 320 On-duty injuries (ODIs), 236–8 ischemia, 90, 120–1, 181, 337, additional costs, 237 353, 356–7 number of work days lost due to, 236–7 necrosis, 128, 291 overall annual odi cost, 238 remodeling, 316–8 sources of injuries, 237–8 rhythm, 106 On-the-job training programs, 26 Myocardium, 93–4, 96, 120–1, 194, 195, 224, Ontological assumption, 414 307–8, 318–9, 335, 337, 354–7 Operations other than war (OOTW), 41 Myoglobin, 148–50, 164 Optical recordings, 190, 192–3 Organ donation, 385 Oxygen saturation, 86, 92, 96, 174, 351 N Nanthakumar, K., 92–3, 119, 137–8, 216 Nasal insufflation, 328, 330 P National Association of Medical Examiners Pacak, K., 183 (NAME), 361 Pacchioni, A., 183 Neunlist, M., 191–2 Pacemakers (PM), 78, 121, 223–4, 228, Neurochemical testing, 386 233, 415 Neuroendocrine effects, 179–84 artificial cardiac, 211 Neuroleptic malignant syndrome (NMS), cardiac, 121, 211 360, 367 hypothetical, 78–9 Neuromuscular activation, 66, 81 implantable, 77 Neuromuscular stimulation, 70 permanent (PMs), 224 NEURON, 56–7 Pain compliance techniques, 261 Ng, W., 204–5 Panescu, D., 63 Nifedipine, 193 Paranoia, 327, 333, 336–7, 365–7, 371 Noise reduction algorithms, 232 PCP, see Phencyclidine Nondeadly force, 24 PEA, see Pulseless electrical activity (PEA) Nonischemic cardiomyopathy, 120 Peak, K., 5 Nonlethal capability sets (NLCS), 45 Pepper spray, see OC spray, 6, 36, 133, 182, Nonlethal force, 24, 26–7, 31, , 44, 46, 270–1, 184, 220, 242–3, 257, 270, 305, 349, 379, 398 359, 367, 379, 399 Nonlethal weapons, 3, 4–9, 23, 28, 35–6, Perchlorates, 45 41–8, 63 Pestaner, J., 332 impact of, 261 Peters, J. G., 407 Nonphysical force, 24 Petrocelli, M., 259 Norepinephrine, 183, 320, 328–30, 334–7, PFT, see Pulmonary function testing 352–3, 355, 357 Phaser-like device, 24 effects of, 306 Phencyclidine, 1–4, 149, 221, 306–7, 327, Null hypothesis, 414 330–4, 336–7, 342–4, 348–9, 356 Photographic documentation, 381, 383–4 Phrenic nerve, 170–1, 177, 293 O dysfunction, 176 O’Halloran, R. L., 351 Physical violence, 248–50, 400 Objective reasonableness standard, 25, Physically resistant suspects, 276 395–6, 399–401 Pneumothorax, 121, 204 Observe-orient-decide-act (OODA), 43–4 Podorski, A. S., 86 Index 455

Point of maximal intensity (PMI), 89, 114, 162 Reporting tool, 30 Police Executive Research Forum (PERF), Respiratory 29, 242, 395 acidosis, 96, 104, 169, 171, 175 Pollanen, M. S., 305 arrest, 176, 327–8 Poor surrogates, 110 depression, 219 Portable vehicle-arresting barrier (PVAB), 45 impairment, 176, 180 Positional asphyxia, 261, 303, 308–9, 348, physiology, 167–71 350–1, 419 anatomy, 170 Postexercise peril, 354–6 cellular respiration, 170 Postmortem redistribution, 338, 341 Restraint asphyxia, 348, 351 Preautopsy checklist, 382 Restraint-related death, 349 Probabilistic causation, 426 Resuscitation, see Cardiopulmonary Prolonged physical struggle, 290 resuscitation (CPR) Prone maximal restraint position Retinal detachment, 205–6, 208 (PMRP), 352 Reversible electroporation, 197 Propidium iodide (PI), 189, 194 Rhabdomyolysis, 85, 143, 149, 163–5, 220, 383 Pseudomonophasic waveform, cocaine-associated, 368 51, 54, 56, 63 physiology of, 163–4 Pseudo-scientific arguments, 17 symptoms of, 165 Psychostimulants, 366–7, 369, 373 Rheoscopic frog, 12, 15 Psychotic symptoms, 365–6, 368, 371 Richardson, A. G., 56 Pudiak, C., 183 Risk management, 1, 235–40 Pulmonary function testing, 351 Rojek, Jeffrey, 257 Pulse delivery probe, 87 Ross, Wolf, 23 Pulseless electrical activity (PEA), 120–1, Roy, O. Z., 86 291, 310, 321, 347, 357, 382, 408 Runners heart, 318 Pump failure, 82 Ruttenber, A. J., 367 Punches, 44, 261 Puncture wounds, 36, 276 Purkinje fibers, 110 S Safety index, 87–8 St. Elmo’s fire, 13 Q Salivary marker, 182 QT prolongation, 318, 357 Sampling error, 420 Satel, S. L., 367 Scalene muscles, 168 R Scarring, 307, 320 Radiofrequency ablation, 78 Scharf, P., 24 Rattay, F., 53–4 Screening tests, 343 RCSD models, 266–7 Sedatives, 112, 212, 307, 311 logistic regression models of deputy Sensing thresholds, 228, 232 injury, 270 Serum logistic regression models of suspect bicarbonate, 175 injury, 271 and skin effect, 143–50 results, 269 troponin, 103 Ready, Justin, 241 Severe acidemia, see acidosis, 104 Reardon, Robert, 153 Sharma, V., 192 Reay, D. T., 351 Sherman, L., 24 Refractory period, 188 Shock-induced hyperpolarization, 190 Reilly, J. P., 54, 66, 197 Shocking to the conscience, 25, 397–8, 400 Reiss, A. J. Jr., 24 Shootingavoidance tools, 5 Remodeling, 315, 316, 318, 320 Short-duration exposures, 112, 135 Renal failure, 143, 149, 164, 383 Sigmaopioid receptor, 337 456 Index

Sine wave, 15, 20, 52, 57–8, 86 Sudden in-custody death, see In-custody Sinus node, 211 death Sinus rhythm, 95–6, 106, 127, 154, 156, Sun, H., 68, 73, 81, 106 159–61, 291 Superficial skeletal muscles, 126 Situation circle, 43 Superhuman strength, 1–3, 327, 333, 367 Skeletal muscle Suspect injuries, 287 activation of, 52, 56, 63 Suspect-related characteristics, 247 anisotropy of the, 70–1 Sweeney, J. D., 51 contraction, 51, 56, 106, 164, 167, 177, Swine model, 416, 418 179, 220 Sympathetic-adrenal-medulla (SAM), 180, force, 52, 56, 59–60 182–4 rheobase and chronaxie values of, 53, 65 Sympathetic nervous system, 328–9, 334–5, Skin-to-heart distance, 99–101, 106, 114, 161 352–5, 357 Skyjackers, 2 Symptomatic bradycardia, 233 Sloane, C., 179 Systemic inflammatory response Small, K. M., 354 syndrome, 309 Smith, M. R., 257, 259 Snorting, 328 Soft empty hand control, 264–6, 268–70, 276 T Soft-hand tactics, 272, 274 Tachyarrhythmia, 156, 160–1, 232, 357 Song, Y. M., 194 See also Cardiac capture Sonographer kneeling, 155 Tachycardia, 95–6, 127, 154, 220, 228 Sonosite titan, 154 Taser CEW discharge, 96, 105–6, 113–5, 197, Sorensen, D. W. M., 257 293 Southall, P. E., 332 Tchou, P., 211, 293 Spatially extended nonlinear node model Telegraph equation, 18 (SENN), 54 Telemetry monitoring, 228 Specimen collection, 338–42 Temporal or association causation blood, 341 theory, 425–6 specimen stability, 342 Temporality, 421–4 tissue and hair, 341 Terrill, W., 25 urine, 340 Tethered projectiles, 19 vitreous humor, 341 Theory of generalizability, 418 Sprains, 259, 268, 276 Thoracic pressure, 121 Standard deviation, 90, 124, 265, 418 Thoracoabdominal exposure, 176 Standoffs, 4 Threat of deadly force, 269–70 Sternocleidomastoid muscle, 168, 293, 386 Thrombus formation, 120 Stimulant abuse, 315–22, 325, 334, 358, Tip-to-heart spacings, 137 366, 374 Tomahawk cruise missile, 45 Strains and lacerations, 268 Touch-stun, 33–4 Stratbucker, R. A., 11, 63, 113 Toxicological analysis, 386 Stratton, S. J., 301 Tracking equipment, 239 Straw causation theory, 425 Transcleral cryotherapy, 204 Strength-duration relationship, 53–4, 122–4 Transdiaphragmatic exposure, 172 String galvanometer, 18 Transmembrane action potential See also Galvanometer morphology, 190–3 Strote, J., 304 Transmembrane electric field, 188 Structural heart disease, 94, 318, 320 Transmembrane potential, 121–8, 189–91, 193 Stun devices, 63 Traumatic apnea, 243 Stun gun, 2, 12, 20–1, 86, 220, 244, 367, 399 Tremulousness, 220 Sudden Cardiac Death, 301, 315–22, 328, Tung, L., 191–3 335–7, 356, 358 T-wave, 90, 182–3 causes of, 120–1 Twisting, 349 Index 457

U Ventricular tachycardia, 95–6, 106, 120, 154, Underwriters laboratories (UL), 12, 291 319, 328 United Nations peacekeepers, 42 Verbal Unmanned ground vehicle (UGV), 48 direction, 264, 267 Urine toxicological tests, 306–7 force, 264 Usage rate versus deployment rate, model Vilke, G. M., 109, 135, 139, 174, 179, 276 of, 285 Violence escalation scale, 253 Use-of-force incidents, 259–61, 263, 267, 405 Volunteer testing vs. field conditions, 212 Vulnerable period, 126

V Vacek, James L., 223 W Valvular disease, 120 Walter, R. J., 105, 137 van der Waals attractions, 188 Webster, John G., 85 Vanga, Subba Reddy, 223 Wetli, C. V., 306, 332, 367, 379 Vascular system, 306–7, 353 White, M. D., 241 Vasoconstriction, 316, 335, 353, 355–7 Witherspoon, S. Robert, 201 Vehicle lightweight arresting device Wittstein, I. S., 182 (VLAD), 45 Wolf, R., 23 Venous blood gas, 172 Wrestling, 43, 260 Ventricular ablation, 110 Wu, J.-Y., 73, 75, 96–101, 106, 113, Ventricular arrhythmia, 93–4, 177, 216, 224, 136–7, 162 357 Ventricular capture, 89–90, 224, 292 X Ventricular dysfunction, 183, 320 Xiphoid process, 89, 102, 106 Ventricular fibrillation (VF), 20, 63, 68, 72, XREP1 device, 176 82, 96, 104–6, 113–4, 119–20, Xylazine, 94 136–8, 145, 154, 161, 211–2, 224–5, Xyphoid process, 94 307, 321, 329, 408 cardiac death due to, 304 danger of, 85 Y induction of, 76, 87, 110, 212, 291 Young, D. B., 355 safety margin for, 223 threshold, 89 Ventricular hypertrophy, see hypertrophy, Z 120, 319 Zhou, X., 192 Ventricular rhythm, 95, 154 Zolazepam, 102, 172