1. Crisis Intervention Team Training
Excited Delirium

2. Excited Delirium Defined
“ A state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without apparent fatigue”
(MORRISON & SADLER, 2001)

3. In Simple Terms Sympathetic nervous system activation
Chemicals are pumped into the body
Primal fight or flight response
The body can only function this way for a limited time
Analogous to putting your car in park and pressing the accelerator to the floor
If it does not slow down eventually you will find a weak point in the “engine”

4. Other Terms Sickle cell sudden death Agitated delirium
Cocaine psychosis
Metabolic acidosis
Exertional Rhabdomyolysis
Positional asphyxia
Sudden custody death
Can we agree something exists?

5. Some Causes Mental illness (bipolar and schizophrenia)
Stimulant drug use and long term abuse
Sudden cessation of drugs (anti-psychotic and street drugs)
Hallucinogenic agents
New drugs (bath salts and K2)
Alcohol withdrawal
Etc.

6. Cause and Presentation
The causes of the excited or agitated state vary but the subjects’ presentations are usually quite similar
When you study all the facts after the event they “read like a script”
Why do we fail to recognize this condition?
Lack of training

7. Training Goals and Objectives
Education on sudden custody death
Education on Excited Delirium Syndrome
Learn to recognize behavioral warning signs of Excited Delirium Syndrome
Collaborate with Dispatchers, LE, and EMS for handling suspected cases
Reduce the potential for a sudden custody death through training

8. Sudden In-Custody Death
An unintentional death that occurs while a subject is in custody. Such deaths usually take place after the subject has demonstrated bizarre and/or violent behavior, and has been restrained
There is often no obvious cause of death found during autopsy
Stating that there usually are not findings on autopsy that can explain the death is true. Amplify this by adding that even in cases of cocaine excited delirium, there usually isn’t enough cocaine found at autopsy to attribute the death to cocaine toxicity.

9. History of Sudden Death Proximal to Restraint
1849 Dr. Luther Bell Physician at McLean Asylum (Mass.) documented 40 cases of a “peculiar form of delirium.” “excitement with fear or rage accompanied with sympathetic nervous system arousal.” Patients required restraints. Three quarters of the cases ended in unexpected fatalities.

10. History Continued
South Carolina Mental Hospital. From there were 360 deaths listed as, “exhaustion due to mental excitement”
In 1946 Dr. Shulack described this phenomenon as “sudden exhaustive death in excited manics”
In 1952 a study by Bellak described the onset symptoms of this syndrome
The problem continues today in mental institutions, nursing homes, and hospitals in situations where restraint is necessary

11. History Continued
During the 1950s excited delirium deaths nearly disappeared
Why???
Development of psychotropic medications
Administered in hospital setting
Re-immergence in the s
Mental illnesses treated outside hospital setting
Stimulant drug use and abuse

12. How Excited Delirium Can Kill?
Body can only do so much before it literally gives out
Under normal conditions the brain sends signals to the body to stop or “calm down” as it nears exhaustion
Persons experiencing Excited Delirium appear able to ignore this safety mechanism
Can push themselves past exhaustion into potentially fatal medical conditions

13. Recognizing Behaviors
Bizarre, violent, aggressive behavior
Violence toward objects
Attack/break glass
Overheating/excessive sweating or very dry
Public disrobing -partial or full (cooling attempt)
Extreme paranoia
Incoherent shouting (animal noises or loud pressured speech)

14. Recognize Behaviors cont.
Irrational physical behavior
Hyperactivity
“Bug Eyes” (They look “nuts”)
Fight or flight response to control attempts
Unbelievable strength
Undistracted by any type of pain

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16. Typical Incident
911 call to Police about a man standing in the street partially naked and/or acting “bizarre”
Obvious to officers that subject will resist
Struggle ensues with multiple officers: May involve O.C., choke holds, baton, ECD, “swarm technique”
Physical restraints applied: Handcuffs/Hobbles
Struggle continues or escalates after restraint
Placed in squad for transport to jail (if you fight with the cops you go to jail)

17. Typical Incident cont. Apparent resolution after restraint
Subject becomes calm or slips into unconsciousness (officers believe the subject is faking or has finally calmed down)
Labored or shallow breathing
Followed unexpectedly by death
Even when death occurs in the care of paramedics or at E.R. resuscitation fails (cardiac rhythm is usually PEA not V-Fib)

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19. Can it Happen in the Fox Valley?
Mid 1980s – (APD #9124 incident) fatality
June (James W.) survived
May (72 hr hold/transport) fatality
Nov (James W.) fatality
Aug Winnebago Co. (car pedestrian) fatality
Sept Neenah PD (ECD use) fatality
March Linwood St – protocol/survived
June Jefferson St – protocol/survived
August 2009-Division St- protocol/survived
August 2011 – Kaukauna PD (fatality)
May 2013 – Riverside Cemetery – protocol survived
June Northland/Ballard- protocol survived

20. Why the Sudden Interest?
Media attention to people dying in POLICE custody
Prior to the 1970s people were dying in mental institutions (“nobody cared”)
The media and other groups have attempted to establish a link between police tactics and unexplained deaths
The only things changing are the police tools/tactics; the underlying factors remain

21. History of Sudden Custody Death and Police Tactics
Choke holds: 1970s through 1980s
“Hogtie” and Positional Asphyxia: 1980s through 1990s
Pepper spray: 1990s
TASER: 2000 to present

22. Excited Delirium Cases Increasing?
Significant rise in street drugs (cocaine, methamphetamines, K2/Bath Salts)
Significant rise in people with mental disorders living outside of mental hospitals (not taking or improperly taking psychotropic medications)
More incidents of Excited Delirium
The problem is going to get worse
Ignoring the problem is a big mistake

23. In-Custody Deaths
The reality is many of the people that die in- custody suffer from one or more medical conditions that contribute to their mortality
Some have high levels of drugs in their bodies that cause adverse reactions
Some are in a mental health crisis (bi-polar disorder or schizophrenia)
The conditions can be worsened when the subject is confronted and restrained by law enforcement officers

24. In-Custody Deaths
LE gets called when the subject suddenly acts bizarre and gets out of control
The resulting bizarre behaviors are caused by the on-going mental/chemical/medical problems
By the time the bizarre behavior occurs they are a long way into the crisis. The “dominos are already falling”
It is too late to start planning your EMS and LE response protocol

25. Early Recognition Training for Dispatchers is critical
Key questions asked during the 911 call are important
Information gathered during the 911 call can start the recognition process
May lead to a simultaneous dispatch of EMS and LE which could save valuable time

26. Incoming Call “there is a guy acting strange, running in circles”
Ask questions to draw out description of behaviors
What specifically is he doing?
Bizarre, violent, aggressive behavior
Violence toward objects
Attack/break glass (windows and mirrors)
Overheating/excessive sweating or very dry (body shut down perspiration production because of over demand on system)
Public disrobing -partial or full (cooling attempt)
Extreme paranoia
Incoherent shouting (animal noises)
Unbelievable strength
Undistracted by any type of pain (including broken bones and damaged limbs. Can easily overpower lone officer)
Irrational physical behavior

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28. Follow Up Questions
Does the caller know the subject? If they do, what do they suspect is causing the behavior?
● Drug ingestion?
1. type
2. how much
3. when
● Drug history?
1. chronic user
2. what type (stimulants, coke, crack, meth.)
Remember that ED in the setting of drug use follows one of three patterns…1) A recent binge superimposed on a long history of abuse (e.g., cocaine excited delirium); 2) Recent abrupt cessation certain anti-psychotic or anti-depressant medications; or 3) use of abuse of a drug that can produce delirium (e.g., mushroom poisoning).

29. Follow Up Continued Mental illness or psychiatric history
1. bi-polar disorder
2. schizophrenia
3. does subject take meds for condition
4. medication compliant
● On-set of behaviors
1. sudden (they just went nuts)

30. If You Suspect Excited Delirium
Give out the behaviors described by caller
Do not just give out the “CAD label”
Dispatch Patrol Supervisor to the scene
Dispatch EMS (Fire?)
Priority response but no lights/siren in the area of incident
Advise EMS to stage in the area
Keep the caller on the line if possible

31. What Officers Should Do
Get EMS on the way prior to confrontation if possible
Avoid confrontation if at all possible
Attempt to contain/isolate the subject without confrontation
Attempt verbal de-escalation
Have as many backup officers as possible

32. Reality
Bizarre/violent behaviors most often will require confrontation and restraint
Restraint can make the problem worse
Without restraint this medical emergency can not be treated
Physical control: expect fight and/or flight
Get the fight over quickly (i.e.TASER, swarm)
Pain compliance will not work
EMS protocol and transport to the hospital

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35. What Do We Do in the Mean Time?
Training
Recognize: an extremely agitated and/or bizarre subject may be more than a “nut case”
Anticipate, recognize, and mobilize EMS before confrontation if possible
Treat these cases as a medical emergency
Protocol driven EMS response

36. Sample EMS Protocol (Gold Cross Ambulance of Fox Valley)
This protocol will be considered anytime during the patient contact when the patient’s behavior indicates the possibility of excited delirium syndrome. Initiate this protocol as early as possible.

37. Protocol Steps Ensure scene safety with law enforcement intervention
Recognize: The warning signs
Identify patient’s “at risk” history
Attempt verbal containment / communication
If verbal de-escalation is ineffective allow law enforcement to contain/control the patient
Secure the patient
If still combative, administer meds
Continuous medical assessment
Transport and radio ahead

38. Scene Safety
As usual procedures require, if for any reason you are concerned about your personal safety contact law enforcement for assistance in dealing with the patient.

39. The Warning Signs Irrational, bizarre behavior
Unbelievable strength and endurance
Aggression toward objects, especially glass or mirrors
Impervious to pain
Resistive to LE tactics
Removal of clothing

40. Warning Signs Continued
Aggression
Hyperactivity
Extreme paranoia
Incoherent Shouting
Grunting or animal like sounds
Perspiration – hyperthermia

41. At Risk History Known drug ingestion or abuse Mental illness
Previous psychiatric history, especially schizophrenia or bi-polar
Taking or failure to take psychiatric medications as prescribed
Sudden onset of behaviors listed earlier

42. Intervention Process
Attempt to de-escalate patient with verbalization. This may not be possible due to patient's behavior
If verbalization is ineffective, allow law enforcement to contain/control subject. Be aware that when confronted a physical altercation may occur
Law Enforcement will most likely use an Electronic Control Device (ECD) or multiple officers
If during containment process 2 successful ECD applications fail to subdue the patient and they continue the excited delirium behaviors, once contained the protocol shall be started and the subject shall be transported to the hospital by ambulance

43. Secure Patient Avoid the use of prone or “hog-tied” positions
Use handcuffs or limb restraints as needed

44. Medical Intervention If subject remains combative….
Administer 5mg Haldol IM, then
Administer 5mg Valium IM
Use 20g needle and inject into lateral thigh, through clothes if necessary
Once meds given, transport to hospital is mandatory

45. Medical Evaluation If possible attempt: Vital signs, including Sp02
Blood Glucose
EKG Rhythm
Body Temperature (very important)
IV Access should only be attempted if it can be safely initiated and maintained
Avoid invasive procedures if patient’s aggression poses a bio-hazard/sharps risk

46. Transport Transport to medical facility
Radio ahead so hospital can make arrangements for security and safety precautions
Transport will include a law enforcement officer riding along in the back of the ambulance if possible