June 16, 2021

Excited Delirium for the TEMS Provider

As a result of some recent high-profile cases, excited delirium (ExDS) has been front and center in the public eye. 1,2,3 Excited delirium is recognized by several national medical organizations including American College of Emergency Physicians 4 and the National Association of Medical Examiners. However, the media often report that ExDS is a fabricated diagnosis to excuse police brutality. While quality data is lacking, there is no doubt that ExDS is an important topic for LE and their TEMS partners. By some estimates, ExDS is ultimately implicated in approximately 3% of police use of force encounters and mortality rates of 12% are cited for ExDS cases in police custody.5 Clearly this is an important topic for Law Enforcement and Tactical Medical Providers (TMP’s).

Since ExDS may be associated with life-threatening conditions such as rhabdomyolysis, hyperkalemia, acidosis, dysrhythmias, and ultimately cardiopulmonary collapse, and since recommended treatment may involve sedation with its potential complications, ExDS is a medical and law enforcement emergency.

The role of the TMP is to assist the transition of the patient from a dangerous, law enforcement concern to a more compliant and less dangerous medical concern. The TMP and others responding to the crisis should be familiar with the signs and symptoms of ExDS. When there is no other way to de-escalate a dangerous and altered person, they must be prepared to step in to guide care. Because of the high fatality rate, TMP’s must recognize ExDS early and encourage rapid control of the person using appropriate measures. Unexpected strength and imperviousness to pain will complicate assessment and treatment.  Medical management can help reduce the amount of force needed to control an altered patient. TMP’s should familiarize themselves with multiple sedative agents given via multiple routes, ensure the patient is closely monitored, and be prepared to manage the cardiorespiratory complications of ExDS and sedation.

The TMP role also extends to care of the LEO after a violent struggle with a violent patient. They should anticipate musculoskeletal injuries, abrasions, and possibly bites. The LEO must be counseled on infectious disease control such as post-exposure prophylaxis. Myocardial infarction is not insignificant in law enforcement officers after a high stress encounter. 6  The TMP should counsel LEO’s to watch for signs and symptoms of acute coronary syndromes, and other complications of physical struggles.

TMP’s must ensure their law enforcement agencies are familiar with ExDS and stress the need for a multidisciplinary approach with pre-hospital and emergency medicine providers. Fostering healthy police-community relations and maximizing outcomes for ExDS encounters is also critical. We need to be a voice in educating the public about the complexities in the care of prehospital care. With the rise in illegal stimulant drug use, ExDS is a problem that is unlikely to go away soon.

As emergency physicians, we are aware of the reality of agitated and violent patients and are not naïve enough to think control and treatment is accomplished easily. Our goal is the same, whether in the field or in the hospital: provide care while keeping all involved safe.

References

  1. https://www.csindy.com/news/springs-man-dies-after-double-dose-of-controversial-drug-ketamine/article_59c6ae4a-a1e9-11eb-b347-176e9ed20620.html  Accessed May 20,2021.
  2. https://www.statnews.com/2021/04/06/excited-delirium-medicalized-racism-organized-medicine-take-a-stand/  Accessed May 20,2021.
  3. https://www.mprnews.org/story/2020/07/13/excited-delirium-cited-in-floyd-case-and-in-other-deaths-involving-law-enforcement  Accessed May 18, 2021.
  4. American College of Emergency Physicians. (Sep 2009). White paper report on excited delirium syndrome. [White paper]
  5. Gonin P, Beysard N, Yersin B, Carron P. Excited delirium: a systematic review. Acad Emerg Med, 2018 May;25(5): 552-65.
  6. https://www.odmp.org/statistics  accessed May 25, 2021.

Dominique Wong, MD
TEMS Newsletter Editor

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