1. Excited Delirium and In-custody Deaths
Michael Abernethy MD FAAEM
Assoc Professor of Emergency Medicine
Univ of Wisconsin SMPH

2. Objectives Excited Delirium Physical Restraints & Use of TAZERS
Medical Management

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

4. Case #1
“Willie went ape shit”

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

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

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

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

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

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

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

12. Physical Restraints
Source: Prehosp Emerg Care, 2003:7(1);

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

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

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

16. Physical Restraint Issues
Compression asphyxia
What are the adverse effects on breathing and circulation when one or more officers kneel on the subjects back as they handcuff him?

17. Thomas A. Swift’s Electric Rifle (TASER)
Source:
Source:
M26 Taser. Manufactured by Taser International

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

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

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

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

22. Taser Red Flag
If anyone exhibits behavior that requires more than 3 taser deployments in order to gain restraint/control – it is a Medical emergency until proven otherwise

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

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

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

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

27. 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
This requires EMS response and transport to the hospital.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

51. Alternative Strategy Attempt verbal de-escalation
Summon back-up quickly
Summon EMS as early as possible
Use taser before a struggle ensues
Jump the subject and administer tranquillizer
Back off and contain the subject without restraint
Once calm transport
Minimize struggle and restraints
Unrealistically simplified?? – Maybe!

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

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

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

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

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

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

58. 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!

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

60. Immediate Exam Core temperature Blood gas CBC and electrolytes
Stat glucose
Toxicology
EKG
Urine for myoglobin
CPK

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

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

63. Summary
Excited Delirium is an imminently life threatening medical emergency, not a crime in progress
In-custody deaths likely related to excited delirium
Tasers – Very useful to gain physical control as an alternative to physical force
ALS medics can give potent tranquilizers
Rapid aggressive medical stabilization needed

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

65. Consider Exited Delirium as Cause of Death
Severe struggle with police with heavy restraint policy used
Sudden collapse and death

66. ED as Cause of Death Toxicology positive for stimulant drugs
Hyperthermia at time of death
Severe acidosis
Rhabdomyolysis
Water all over the scene
Broken glass
Heart or lung disease on autopsy