Page 72 - Journal of Special Operations Medicine - Spring 2015

Review, Clinical Update, and Practice Guidelines
for Excited Delirium Syndrome

Kevin B. Gerold, DO, JD; Mark E. Gibbons, EMT-P;
Richard E. Fisette Jr, PA; Donald Alves, MD

ABSTRACT
Excited delirium syndrome (ExDS) is a term used to patients who experienced bizarre and aggressive behav­
describe patients experiencing a clinical condition char­ ior in association with an altered mental status, often in
acterized by bizarre and aggressive behavior, often in as­ combination with other symptoms that included disrob­
sociation with the use of chronic sympathomimetic drug ing or wearing clothing inappropriate for conditions,
abuse. The agitated and disruptive behavior of persons failing to comply with verbal commands by police, yell­
with ExDS often results in a call to police resulting in ing or making guttural sounds, attacking inanimate ob­
an arrest for disorderly conduct. The suspect’s inability jects, attraction to light, and a propensity to break glass.
to comply with police commands during the arrest fre­ When attempts were made to restrain these individu­
quently results in a struggle and the use of physical or als, they often exhibited “superhuman” strength and
chemical control measures, including the use of conduc­ an unwillingness to yield despite overwhelming force.
tive energy weapons (CEWs). Deaths from this hypermeta­ One study reported that four officers were on average
bolic syndrome are infrequent but potentially preventable required to subdue these individuals (range 3–6).
with early identification, a coordinated aggressive police
intervention, and prompt medical care. Preliminary expe­ Police officers must continually adapt to changing
riences suggest that ExDS is a medical emergency treated threats that include contact with emotionally unstable
most effectively using a coordinated response between and potentially violent individuals, often in association
police officers and emergency medical providers. Once with mental illness or drug abuse. When these individu­
the person suspected of experiencing ExDS is in custody, als violate the law and fail to comply with lawful orders,
medical providers should rapidly sedate noncompliant police officers and citizens are placed at risk for physical
patients with medications such as ketamine or an anti­ harm during and unfolding, dynamic, and potentially
psychotic drug such as haloperidol in combination with life­threatening encounter. Police and medical practitio­
a benzodiazepine drug such as midazolam or diazepam. ners are increasingly recognizing these types of encoun­
Once sedated, patients should undergo a screening medi­ ters as medical emergencies that require the education
cal assessment and undergo initial treatment for condi­ and training of police officers, emergency medical ser­
tions such as hyperthermia and dehydration. All patients vices (EMS) responders, and hospital staff in how best
exhibiting signs of ExDS should be transported rapidly to manage these encounters effectively.
to a medical treatment facility for further evaluation and
treatment. This article reviews the epidemiology, clinical Medical experts continue to disagree about whether
presentation, diagnosis, and treatment options for ExDS. ExDS is a unique medical condition warranting its own
diagnosis or is a variant of an existing psychiatric disor­
Keywords: excited delirium, excited delirium syndrome, der. Those advocating that ExDS is a unique condition
delirium, sudden death, in-custody death, hyperthermia, note that it occurs in susceptible individuals in asso­
sympathomimetic drug use, cocaine, phencyclidine, lysergic ciation with the use of stimulants, especially cocaine,
acid diethylamide, ketamine, haloperidol, TASER, conduc- though cases have occurred in association with metham­
tive energy weapon, Agitated Chaotic Event , ACE, medical phetamine, PCP, and LSD. Cocaine use is known to cause
™
emergency, emergency medical services, police increases brain levels of the neurotransmitters dopamine
and serotonin. Increased levels of these neurotransmit­
ters are responsible for the addictive properties of this
drug and contribute to hyperactivity and hyperthermia.
Introduction
Chronic cocaine use induces a physiologic change in
the regulation of dopamine and serotonin, which may
ExDS is a term first attributed to the Miami Medical Ex­ be neuroprotective. Persons who experience ExDS may
aminer’s Office in 1985. It was used to describe a class of have an unusual genotype or phenotype that prevents

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