1. 1 Excited Delirium and In-custody Deaths Richard Barney, MD FACEP Assistant Clinical Professor of Medicine UW Medflight EMS Medical Director- Rock County Beloit Memorial Hospital

2. 2 In-Custody Deaths… Why do some people die following a violent confrontation with police? Why do some people die following a violent confrontation with police? What role does the taser play, if any? What role does the taser play, if any? What role does position of the patient play What role does position of the patient play What can police officers do to prevent in- custody deaths? What can police officers do to prevent in- custody deaths? What is EMS Role? What is EMS Role? What is the ER Role? What is the ER Role?

3. 3 Typical Scenario Male subject creating a disturbance Male subject creating a disturbance Triggers 911 call Triggers 911 call Obvious to police that subject will resist Obvious to police that subject will resist Struggle ensues with multiple officers Struggle ensues with multiple officers May involve OC, Taser, choke holds, batons, etc. May involve OC, Taser, choke holds, batons, etc.

4. 4 Typical Scenario Physical restraints applied Physical restraints applied Subject subdued in a prone position Subject subdued in a prone position Officers kneeling on subjects back Officers kneeling on subjects back Handcuffs, ankle cuffs Handcuffs, ankle cuffs Hogtying, hobble restraint Hogtying, hobble restraint Prone vs. lateral positioning Prone vs. lateral positioning Transported in a squad car to jail Transported in a squad car to jail

5. 5 Typical Scenario Continued struggle against restraints Continued struggle against restraints Sometimes damages squad car Sometimes damages squad car Apparent resolution period Apparent resolution period Subject becomes calm or slips into unconsciousness Subject becomes calm or slips into unconsciousness Labored or shallow breathing Labored or shallow breathing Followed unexpectedly by… Followed unexpectedly by…

6. 6 Typical Scenario Death Death Resuscitation efforts are futile Resuscitation efforts are futile Los Angeles County EMS Study Los Angeles County EMS Study 18 ED deaths witnessed by paramedics (all were restrained) 18 ED deaths witnessed by paramedics (all were restrained) In 13 – rhythm documented In 13 – rhythm documented VT and asystole were most common VT and asystole were most common No ventricular fibrillation No ventricular fibrillation All failed resuscitation All failed resuscitation Source: Am J Emerg Med; 2001:19(3), 187-191

7. 7 Typical Scenario The press: The press: Subject “died after being shocked with taser” Subject “died after being shocked with taser” Implies cause and effect Implies cause and effect The Fallacy: “Post hoc ergo proptor hoc ” The Fallacy: “Post hoc ergo proptor hoc ”

8. 8 Typical Aftermath Several weeks later – autopsy results… Several weeks later – autopsy results… Cause of Death Cause of Death Excited delirium Excited delirium Illicit stimulant drug abuse Illicit stimulant drug abuse Concurrent medical problems Concurrent medical problems Minimal injury from police confrontation Minimal injury from police confrontation It wasn’t the taser after all It wasn’t the taser after all Officers exonerated Officers exonerated

9. 9 Restraints and In-Custody Deaths What roles do physical restraint, restraining technique and restraint position play in excited delirium deaths? What roles do physical restraint, restraining technique and restraint position play in excited delirium deaths?

10. 10 Physical Restraints Source: Prehosp Emerg Care, 2003:7(1); 48-55.

11. 11 Physical Restraint Issues Positional Asphyxia Positional Asphyxia Deaths have occurred with subjects restrained in a prone position Deaths have occurred with subjects restrained in a prone position Theory: restricts breathing Theory: restricts breathing The role of the position is unclear The role of the position is unclear Little data to support causality Little data to support causality Other factors are the likely culprits Other factors are the likely culprits

12. 12 Physical Restraint Issues No clinically significant changes in pulmonary function tests in healthy volunteers No clinically significant changes in pulmonary function tests in healthy volunteers Am J Forensic Med Pathol. 1998 Sep;19(3):201-5. Am J Forensic Med Pathol. 1998 Sep;19(3):201-5.

13. 13 Physical Restraint Issues Restraint Asphyxia Restraint Asphyxia Increased deaths in restrained patients Increased deaths in restrained patients Rat Study Rat Study 3 fold increase in cocaine-related deaths among “restrained” rats 3 fold increase in cocaine-related deaths among “restrained” rats Life Sci. 1994;55(19):PL379-82. Life Sci. 1994;55(19):PL379-82. Numerous studies now show restraint position not causative of death Numerous studies now show restraint position not causative of death Routinely now rejected in the courts Routinely now rejected in the courts It isn’t the restraint that kills them, it is the Excited Delirium. It isn’t the restraint that kills them, it is the Excited Delirium.

14. 14 Thomas A. Swift’s Electric Rifle (TASER) M26 Taser. Manufactured by Taser International Source: http://www.keme.co.uk/~mack/M26.jpgSource: http://www.pointshooting.com/m26black.jpg

15. 15 Tasers, in and of themselves, are not lethal weapons.

16. 16 Tasers Use Electricity It’s not the voltage it’s the amperage that is dangerous It’s not the voltage it’s the amperage that is dangerous Tasers use high voltage, but very low amperage Tasers use high voltage, but very low amperage M26: 3.6 milliamps (average current) M26: 3.6 milliamps (average current) M26:1.76 joules per pulse M26:1.76 joules per pulse X26: 2.1 milliamps (average current) X26: 2.1 milliamps (average current) X26: 0.36 joules per pulse X26: 0.36 joules per pulse X26 Taser delivers 19 pulses per second X26 Taser delivers 19 pulses per second

17. 17 Taser Effects High voltage affects nerves High voltage affects nerves Leads to intense muscle contraction Leads to intense muscle contraction Does not affect muscles directly Does not affect muscles directly

18. 18 Taser Safety 215,000 officer have received taser “ride” in training Over 500,000 reported taser deployments to date No causal effects for death found

19. 19 Academic Emer. Med. 2006 June;13(6):589-95 After 5 second taser ride on numerous subjects: After 5 second taser ride on numerous subjects: No EKG changes No EKG changes No cardiac cell injury No cardiac cell injury No hyperkalemia No hyperkalemia No acidosis No acidosis

20. 20 There is no scientific evidence to date of a cause and effect relationship between Tasers and in- custody deaths.

21. 21 Several forensic pathology studies have cited excited delirium, not Tasers, as the cause of death.

22. 22 What is Excited Delirium? An imminently life threatening medical emergency… An imminently life threatening medical emergency… Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain. Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain. Severe delirium and agitation Severe delirium and agitation Not a crime in progress! Not a crime in progress!

23. 23 The “Freight Train to Death” How police restrain or position the subject will not stop “the freight train to death” How police restrain or position the subject will not stop “the freight train to death” The sooner the severe agitation is terminated, the better The sooner the severe agitation is terminated, the better This requires EMS response and transport to the hospital. This requires EMS response and transport to the hospital.

24. 24 What is Excited Delirium? Diagnostic criteria Diagnostic criteria Characteristic behavioral components Characteristic behavioral components Metabolic Acidosis Metabolic Acidosis Hyperthermia Hyperthermia Identifiable cause Identifiable cause Stimulant drugs Stimulant drugs Psychiatric disease Psychiatric disease Alcohol or medical problems rarely can cause Alcohol or medical problems rarely can cause It does not explain all behavior that leads to confrontation with police It does not explain all behavior that leads to confrontation with police

25. 25 Pathophysiology Central nervous system effects: Central nervous system effects: Changes in dopamine transporter and receptors Changes in dopamine transporter and receptors High release of other neurotransmitters High release of other neurotransmitters Accounts for behavioral changes Accounts for behavioral changes Accounts for hyperthermia Accounts for hyperthermia

26. 26 Behavioral Components: Delirium Delirium: Delirium: “Off the track” “Off the track” Confusion Confusion Clouding of consciousness Clouding of consciousness Shifting attention Shifting attention Disorientation Disorientation Hallucinations Hallucinations Onset rapid – acute Onset rapid – acute Duration brief – transient Duration brief – transient

27. 27 Behavioral Components: Excited (Agitated) Extreme agitation, increased activity Extreme agitation, increased activity Aggravated by efforts to subdue and restrain Aggravated by efforts to subdue and restrain Not likely to comply after one or two tasers Not likely to comply after one or two tasers Pressured speech, grunting Pressured speech, grunting Inappropriate words and flight of ideas. Inappropriate words and flight of ideas.

28. 28 Behavioral Components: Excited (Agitated) Violent or aggressive behavior Violent or aggressive behavior Towards inanimate objects, especially smashing glass Towards inanimate objects, especially smashing glass Towards self, others or police Towards self, others or police Noncompliant with requests to desist Noncompliant with requests to desist Superhuman strength Superhuman strength Insensitive to pain Insensitive to pain

29. 29 Excited Delirium Hyperthermia Hyperthermia High body temperature High body temperature 105 – 113 o F 105 – 113 o F Drug’s effect on temperature control center in brain (hypothalamus) Drug’s effect on temperature control center in brain (hypothalamus) Tell-tale signs: Tell-tale signs: Profuse sweating Profuse sweating Undressing – partial or complete Undressing – partial or complete

30. 30 Excited Delirium Hyperthermia Hyperthermia Aggravated by Aggravated by increased activity increased activity the ensuing struggle the ensuing struggle warm humid weather (summertime) warm humid weather (summertime) dehydration dehydration certain therapeutic medications certain therapeutic medications

31. 31 Excited Delirium Metabolic Acidosis Metabolic Acidosis Potentially life threatening Potentially life threatening Elevated blood potassium level Elevated blood potassium level Factors: dehydration, increased activity Factors: dehydration, increased activity Survivors: Survivors: Kidney damage due to muscle breakdown Kidney damage due to muscle breakdown May require dialysis May require dialysis

32. 32 Excited Delirium: The Usual Suspects #1 Cause: Stimulant Drug Abuse #1 Cause: Stimulant Drug Abuse Acute intoxication Acute intoxication Superimposed on chronic abuse Superimposed on chronic abuse Acute intoxication triggers the event Acute intoxication triggers the event

33. 33 Excited Delirium: The Usual Suspects Underlying psychiatric disease Underlying psychiatric disease First described in 1849 before cocaine was first extracted from cocoa leaf First described in 1849 before cocaine was first extracted from cocoa leaf Mania (Bipolar Disorder) Mania (Bipolar Disorder) Psychosis (Schizophrenia) Psychosis (Schizophrenia) Noncompliance with medications to control psychosis or bipolar disorder Noncompliance with medications to control psychosis or bipolar disorder Unusual – #2 Cause Unusual – #2 Cause Rare: New onset schizophrenia Rare: New onset schizophrenia

34. 34 Stimulant Drugs Cocaine Cocaine The major offender The major offender On the rise due to “crack epidemic” On the rise due to “crack epidemic” Toxicology studies show… Toxicology studies show… Low to moderate levels of cocaine Low to moderate levels of cocaine High levels of benzoylecognine (the major breakdown product of cocaine) High levels of benzoylecognine (the major breakdown product of cocaine) Suggests recent use superimposed on chronic abuse Suggests recent use superimposed on chronic abuse

35. 35 Stimulant Drugs Other known culprits include: Other known culprits include: Methamphetamine Methamphetamine Phencyclidine (PCP) Phencyclidine (PCP) LSD LSD Cocaethylene = Cocaine + Alcohol Cocaethylene = Cocaine + Alcohol Toxic to the heart Toxic to the heart Unknown role in excited delirium deaths Unknown role in excited delirium deaths

36. 36 Concurrent Health Conditions Obesity Obesity Heart Disease Heart Disease Coronary artery disease Coronary artery disease Cardiomegaly Cardiomegaly Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy Myocarditis Myocarditis Fibrotic heart Fibrotic heart

37. 37 Autopsy Proof Specialized laboratories can identify changes in brain chemistry that are characteristic of excited delirium Specialized laboratories can identify changes in brain chemistry that are characteristic of excited delirium Blood and brain tissue levels of benzoylecognine and cocaine Blood and brain tissue levels of benzoylecognine and cocaine Typical ratio 5:1 Typical ratio 5:1

38. 38 Tasers and Excited Delirium Deaths It’s not the Taser It’s not the Taser Many in-custody deaths long before tasers were ever used Many in-custody deaths long before tasers were ever used Documented in 1980s medical literature Documented in 1980s medical literature Deaths of persons not in custody Deaths of persons not in custody Found naked in bathrooms Found naked in bathrooms Wet towels Wet towels Empty ice cube trays scattered about Empty ice cube trays scattered about A futile effort to cool themselves A futile effort to cool themselves

39. 39 Excited delirium is an imminently life- threatening medical emergency.

40. 40 The behavioral features of excited delirium include criminal acts, but…

41. 41 Excited delirium is not a crime in progress, and responders must recognize the difference, before it’s too late.

42. 42 Recognizing Excited Delirium Agitation or Excitement = Increased activity and intensity Agitation or Excitement = Increased activity and intensity Aggressive, threatening or combative – gets worse when challenged or injured Aggressive, threatening or combative – gets worse when challenged or injured Amazing feats of strength Amazing feats of strength Pressured loud incoherent speech Pressured loud incoherent speech Sweating (or loss of sweating late) Sweating (or loss of sweating late) Dilated pupils/less reactive to light Dilated pupils/less reactive to light Rapid breathing Rapid breathing

43. 43 Recognizing Excited Delirium Delirium = Confusion Delirium = Confusion Disoriented Disoriented Person, place, time, purpose Person, place, time, purpose Rapid onset over a short period of recent time Rapid onset over a short period of recent time “He just started acting strange” “He just started acting strange” Easily distracted/lack of focus Easily distracted/lack of focus Decreased awareness and perception Decreased awareness and perception Rapid changes in emotions (laughter, anger, sadness) Rapid changes in emotions (laughter, anger, sadness)

44. 44 Recognizing Excited Delirium Psychotic = bizarre behavior Psychotic = bizarre behavior Thought content inappropriate for circumstances Thought content inappropriate for circumstances Hallucinations (visual or auditory) Hallucinations (visual or auditory) Delusions (grandeur, paranoia or reference) Delusions (grandeur, paranoia or reference) Flight of ideas/tangential thinking Flight of ideas/tangential thinking Makes you feel uncomfortable Makes you feel uncomfortable

45. 45 Bad Behavior: Other Reasons Alcohol intoxication or withdrawal Alcohol intoxication or withdrawal Other drug use problems Other drug use problems Example: Cocaine psychosis Example: Cocaine psychosis Pure psychiatric disease Pure psychiatric disease Head injury Head injury Dementia (Alzheimer’s Disease) Dementia (Alzheimer’s Disease) Hypoglycemia Hypoglycemia Hyperthyroidism Hyperthyroidism

46. 46 Patients with excited delirium need rapid aggressive medical intervention.

47. 47 Alternative Strategy Attempt verbal de-escalation Attempt verbal de-escalation Summon back-up quickly Summon back-up quickly Summon EMS as early as possible Summon EMS as early as possible Use taser before a struggle ensues Use taser before a struggle ensues Jump the subject and administer tranquillizer Jump the subject and administer tranquillizer Back off and contain the subject without restraint Back off and contain the subject without restraint Once calm transport (no restraints?) Once calm transport (no restraints?) Minimize struggle and restraints Minimize struggle and restraints Unrealistically simplified?? – Maybe! Unrealistically simplified?? – Maybe!

48. 48 The first goal of therapy is to gain control of the violent behavior.

49. 49 The “Ideal” Drug Rapid effective tranquilization Rapid effective tranquilization No repeat dosing No repeat dosing No significant adverse effects No significant adverse effects respiratory depression respiratory depression cardiovascular depression cardiovascular depression neurological adverse effects neurological adverse effects Easy to administer (IM) Easy to administer (IM) Allows easy assessment of neurological status on ED arrival Allows easy assessment of neurological status on ED arrival

50. 50 In Search of The “Ideal” Drug Benzodiazepines Benzodiazepines Neuroleptics Neuroleptics Atypical antipsychotics Atypical antipsychotics Ketamine Ketamine

51. 51 Benzodiazepines Effective Effective But usually require repeat doses But usually require repeat doses Adverse reactions: Adverse reactions: Hypotension Hypotension Respiratory Depression Respiratory Depression Too long to take effect Too long to take effect Over sedation Over sedation

52. 52 Neuroleptics and Atypical Antipsychotics Rapid onset (10 – 15 minutes or less) Rapid onset (10 – 15 minutes or less) Do we have 15 minutes?? NO Do we have 15 minutes?? NO Can be very effective in a single dose Can be very effective in a single dose Prolong the QT Interval (Droperidol) Prolong the QT Interval (Droperidol) Target dopamine D2 receptors Target dopamine D2 receptors May exacerbate hyperthermia May exacerbate hyperthermia HALDOL or GEODON HALDOL or GEODON

53. 53 Ketamine Very rapid onset of action (<5 minutes) Very rapid onset of action (<5 minutes) Highly effective in a single dose Highly effective in a single dose Favorable safety profile in healthy patients Favorable safety profile in healthy patients Potential adverse effects: Potential adverse effects: Adrenergic over stimulation in excited delirium Adrenergic over stimulation in excited delirium “Emergence reactions” in adults “Emergence reactions” in adults Dose 3-4 mg/Kg IM Dose 3-4 mg/Kg IM

54. 54 Rapid Chemical Sedation is Life-saving Get a chemical restraint drug into the patient at once. Remove physical restraints when feasible Never allow hobble or prone restraint!

55. 55 The second goal of therapy is to stabilize the underlying pathophysiologic processes.

56. 56 Immediate Exam Core temperature Blood gas CBC and electrolytes Stat glucose ToxicologyEKG Urine for myoglobin CPK

57. 57 Immediate Treatment Dehydration/Metabolic Acidosis: Dehydration/Metabolic Acidosis: IV NS X 2 W/O Get ABG Bicarb for under 7.0 IV NS X 2 W/O Get ABG Bicarb for under 7.0 Hyperthermia: Hyperthermia: Cool environment, disrobe, tepid mist and fanning, cooling blankets Cool environment, disrobe, tepid mist and fanning, cooling blankets Hyperkalemia?: Hyperkalemia?: Fluids, Calcium Chloride, Sodium Bicarbonate, Albuterol Fluids, Calcium Chloride, Sodium Bicarbonate, Albuterol

58. 58 Psychiatric History Diagnosis Diagnosis On Meds? On Meds? Has patient stopped meds? Has patient stopped meds? Schizophrenia Schizophrenia Personality disorder Personality disorder Manic disorder Manic disorder

59. 59 Summary Excited Delirium is an imminently life threatening medical emergency, not a crime in progress Excited Delirium is an imminently life threatening medical emergency, not a crime in progress In-custody deaths likely related to excited delirium In-custody deaths likely related to excited delirium Tasers – if used early – may help (remains unproven) Tasers – if used early – may help (remains unproven) ALS medics can give potent tranquilizers ALS medics can give potent tranquilizers Rapid aggressive medical stabilization needed Rapid aggressive medical stabilization needed

60. 60 Summary Beware of potential side effects of therapeutic drugs Beware of potential side effects of therapeutic drugs Treat for hyperthermia, dehydration, metabolic acidosis and potential hyperkalemia Treat for hyperthermia, dehydration, metabolic acidosis and potential hyperkalemia