Page 73 - Journal of Special Operations Medicine - Spring 2015

the protective adaptation to cocaine use. This failure exhaustion death, exhaustion psychosis, fulminating
to alter neurotransmitter regulation to cocaine or other psychosis, and exhaustive syndrome, this condition af­
stimulant use results in high dopamine levels and a hy­ fected predominantly women with psychiatric disor­
peractive autonomic nervous system, which may predis­ ders. These patients presented with agitation, anorexia
4
pose to ExDS. 1 (lack of appetite), fever, and increasing confusion. Mor­
tality occurred in 75% to 100% of cases, and death
The American College of Emergency Physicians (ACEP) was attributed to exhaustion. With the introduction of
and the National Association of Medical Examiners antipsychotic medications such as chlorpromazine and
(NAME) recognize ExDS as a unique clinical syndrome. haloperidol, this condition virtually disappeared until
The American Medical Association (AMA) and the the 1980s, when it reemerged as an acute form in asso­
American Psychiatric Association (APA) do not, and it is ciation with stimulant use, primarily cocaine, metham­
not listed in the International Classifications of Disease, phetamine, and phencyclidine.
Ninth Revision (ICD­9). Under existing ICD­9 codes,
ExDS can be classified as 296.00S Manic Excitement; In a historical analysis of death in custody, Grant and
293.1J Delirium of Mixed Origin; 292.81Q Delirium, colleagues conducted a retrospective review spanning 34
drug induced; 292.81R Delirium, induced by drug; years. The Maryland Office of the Chief Medical Exam­
307.9AD Agitation; 780.09E Delirium; 799.2AM Psy­ iner reviewed a cohort of 145,425 cases occurring be­
chomotor Excitement; 799.2V Psychomotor Agitation; tween 1939 and 2004. From their review, they were able
or 799.2X Abnormal Excitement. The upcoming ICD­ to identify only 202 (0.14%) in­custody deaths. They
5
10 is also without a specific ExDS code, relying instead concluded that cardiovascular disease was the most
on the F10–F19 group of Mental and Behavioral Disor­ common cause of in­custody deaths until the 1970s,
ders due to Psychoactive Substance Use or F43 Reaction except for the 1940s, where the primary causes of in­
to Severe Stress, and Adjustment Disorders. custody death was due to complications from syphilis
and tuberculosis. Suicide while in custody predominated
in the 1980s, with 44% due to hanging.
History of Police In-custody
Deaths and Excited Delirium
“Undetermined” as a cause of death emerged in the
In­custody deaths always evoke controversy. Deaths in­ 1980s and became the dominant cause of death from
custody from undetermined causes typically occur sud­ the 1990s. Most of these deaths were attributed to
denly and unexpectedly, and autopsy findings provide drug intoxication involving cocaine (36%) and nar­
minimal physical findings to explain it. This unexpected cotics (31%). The authors concluded that death while
nature of these events and the absence of objective evi­ in­ custody was rare historically, that death from un­
dence supporting a clear cause of death challenge the dermined causes did not emerge until the 1980s, and
reputations of police departments and strain relations that death from an undetermined cause accounts for the
within their community. Allegations of police brutality majority of in­custody deaths since 1990. The authors
and conspiracy to conceal police activities frequently suggested that unexpected death in custody coincided
occur. and some have asserted that ExDS is a hoax to with an increase in the abuse of stimulants. Within the
cover up the inherent dangers of CEWs (TASER). Law last few years, some have proposed abandoning the
2
enforcement and correctional officers involved in such term “excited delirium syndrome” in favor of “agitated
events are frequently stigmatized and experience profes­ chaotic event ” (ACE), a term that better describes this
™
sional pressure and personal stress. condition and avoids the social stigma associated with
this condition. 6
Investigations into in­custody deaths occurring over the
past two decades have concluded that these occurrences The same authors conducted a similar study attempt­
are very rare. Since the 1990s, the majority of in­custody ing to identify the frequency of in­custody ExDS deaths.
deaths arise from an undetermined cause. Most occur in They performed a retrospective review of 353,029
association with a series of factors that include a history deaths reviewed by the Maryland Office of the Chief
of stimulant use, a struggle, the use of restraints, and the Medical Examiner spanning 1939 to 2005. The au­
7
existence of coexisting disease. When combined, the re­ thors identified 62 custodial death cases that listed
sult can be sudden death. Many of the previously unex­ excited or agitated delirium as a cause of death and/
3
plained in­custody deaths are now attributed to ExDS. or who died while demonstrating characteristics associ­
ated with ExDS. Of the 62 cases, 48 (77%) occurred
ExDS is not a new medical condition. A chronic form between 1980 and 2005. The mean age of the dece­
of ExDS was observed commonly in psychiatric insti­ dents was 38 years (range 18 to 71 years). Ninety­four
tutions from 1850 to 1950. Originally termed lethal percent were male, and 63% were African American.
or malignant catatonia, Bell’s mania, manic delirium, Forty­one (66%) deaths occurred while in the custody

Excited Delirium Syndrome 63