Page 75 - Journal of Special Operations Medicine - Spring 2015

physiologic changes, cardiac arrhythmias, or myocar­ Table 1 Differential Diagnosis of Excited Delirium
dial ischemia. Advocates for the use of CEWs further Differential Diagnosis of Excited Delirium
19
argue that these weapons reduce injuries to suspects
and police officers by terminating situations that might Drug or alcohol intoxication
otherwise culminate in sudden in­custody death in as­ Drug or alcohol withdrawal
sociation with ExDS. Hypoxemia
Electrolyte disorder
Despite ongoing arguments for and against the safety
of CEWs, the scientific evidence remains insufficient to Thyroid storm
determine whether the use of CEWs increases the prob­ Sepsis
ability of sudden in­custody death in the presence of co­ Seizure disorder
factors such as mental illness or ExDS. However, it is Traumatic brain injury
reasonable to conclude that the weapon’s proven effec­
tiveness in inducing compliance and promoting officer Heat stroke
safety outweighs concerns for the minimal likelihood Serotonin syndrome
that a CEW will be the sole cause of a sudden in­custody Neuroleptic malignant syndrome
death. Further research is needed in order to more fully
determine whether there is a causal association between Table 2 Features Associated With Excited Delirium Syndrome
CEW use and in­custody death. Until future investiga­ Frequency, %
tions are able to clarify this concern, police officers and Feature (95% confidence interval)
medical practitioners should assume that persons ex­
posed to a CEW discharge exceeding a cumulative expo­ Tolerance to pain 100 (83–100)
sure of 15 seconds, especially when used in association Tachypnea 100 (83–100)
with prolonged struggling, altered mental status, and Sweating 95 (75–100)
suspected drug intoxication, are experiencing ExDS and Agitation 95 (75–100)
promptly refer these individuals for medical evaluation Hyperthermia to touch 95 (75–100)
and treatment. The Model Electronic Control Weap­
20
ons (ECW) Policy from the International Association of Noncompliance to police 90 (68–99)
Chiefs of Police (IACP) advocates a medical evaluation commands
for persons subjected to a CEW when, “he or she has Lack of tiring 90 (68–90)
been exposed to more than three ECW cycles, . . . ex­ Unusual strength 90 (68–90)
posed to the effects of more than one ECW device, . . . Dressed inappropriately for
believed to have been exposed to a continuous cycle of environment 70 (45–88)
15 seconds or more, . . . [or] exhibits signs of ‘excited Attraction to mirrors or glass 10 (not reported)
delirium.’” 21

Technology Working Group on Less Lethal Devices has
Diagnosis of ExDS
prepared an Excited Delirium pocket card useful for po­
While there is no uniform definition of ExDS, this syn­ lice officers and EMS responders (Figure 1). 23
drome should be suspected in any individual exhibiting
abnormal behavior including agitation and six or more Treatment of ExDS
of 10 criteria identified by Hall et al. In their study of
22
more than 1 million police encounters during a 2­year The priorities for the initial treatment of patients with
period, they identified features associated with ExDS. ExDS are control and restraint, rapid sedation, and
These included a high tolerance to pain, tachypnea, transport to a hospital for definitive care. In the absence
sweating, agitation, hyperthermia to touch, noncom­ of clinical studies on the best treatment for this poten­
pliance with police commands, absence of fatigue, un­ tially lethal condition, clinicians must rely on consensus­
usual strength, dressing inappropriately for conditions, driven guidelines.
and an attraction to mirrors or glass (see Tables 1 and
2 for a list of differential diagnoses and ExDS criteria). The appropriate response to patients with ExDS should
Police officers and medical personal should have an ad­ begin with dispatch. When an operator receives a call
ditional heightened suspicion for ExDS whenever the involving someone manifesting signs of ExDS, the call
person exhibiting signs of ExDS is male (mean age 36 center should simultaneously dispatch law enforcement
years) or is suspected of using or withdrawing from the and EMS teams. First responding EMS units should
24
use of stimulants, such as methamphetamine, PCP, LSD, stage at a safe location until police officers have evalu­
and especially cocaine. The National Institute of Justice ated the call and rendered conditions safe for EMS to

Excited Delirium Syndrome 65