HOW TO RESPOND TO

EXCITED
PHOTO: ©ISTOCKPHOTO.COM

This mysterious
condition is a
primary cause of
in-custody death,
and YOU NEED TO
KNOW how to
recognize it.
JEFFREY D. HO, MD, FACEP

DELIRIUM
BECAUSE YOU, as law enforcement officers, are often required to control subjects in various stages of agitation, it is important for you to understand that some
of these subjects will be in a state of extreme physiologic stress. This state is
often called “excited or agitated delirium.”
The condition of Excited Delirium is
associated with a high risk of sudden
death and is recognizable by its constellation of symptoms and signs,
which may include: agitation, incoherence, elevated body temperature, paranoia, inappropriate and often violent
behavior, constant motion, and feats of
incredible strength.

NO SINGLE CAUSE
Subjects experiencing Excited Delirium have died in various situations,
sometimes after exposure to less-thanlethal weapons. But research into the
effects of pepper spray, TASERs, and
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some restraint techniques has been
performed to determine their role in
Excited Delirium, and no single cause
has been identified.
Most credible experts believe that Excited Delirium allows a subject to exhaust himself to death and that this
phenomenon is independent of any device or technique used upon the subject. These beliefs are largely supported
by the known scientific research.
Excited Delirium is generally considered to be a potentially life-threatening
medical emergency because of the significant metabolic stress that it can
place on the body and the fact that the
subject experiencing it does not recognize the seriousness of his or her own
condition.
Risk factors for developing this condition appear to include male gender,
illicit stimulant abuse (usually long
term), a known underlying mental ill-

ness disorder (especially schizophrenia
and paranoid conditions), or a history
of taking mental illness medications.
You can probably think of numerous
persons in your own community who
have several of these risk factors. Being
aware of these subjects in advance may
be advantageous to you, as they represent a segment of your own community
that is likely to be at higher risk for this
type of problem to develop.

WHAT YOU CAN DO
Since Excited Delirium is a medical
condition, you may wonder what you,
the patrol officer, can do to render aid
in these situations.
There are generally two basic things
that you can initiate in your own work
practices that will greatly assist these
people.
Learn to Recognize the Condition—
Perhaps one of the more difficult

EXCITED DELIRIUM
things to learn is recognition of Excited Delirium. While the subject’s behavior may be of law enforcement
concern and the person must be controlled for the safety of themselves and
those around them (a primary law enforcement duty), he or she must also
be evaluated by medical professionals
sooner rather than later. The only way
that this will happen is for you to recognize the condition early on. Delirious, agitated, and inappropriate behavior is the best way to recognize
Excited Delirium. This is much different than the often slowed, dulled, and
inappropriate behavior of simple alcohol intoxication.
I have reviewed hundreds of sudden
death reports in my research and some
common behavior themes in Excited
Delirium cases are:
Inappropriately running in traffic
Partial or full public nudity
Inappropriate and unprovoked acts
of violence such as attacking windows,
homes, cars, lights, etc.
If you recognize this behavior upon

arrival and can correlate it with some
of the risk factors or other
symptoms/signs as described above, it
is likely that you are dealing with a
case of Excited Delirium.
Call for Help—One of the first things
you should do upon recognizing an Excited Delirium case is to call for backup.
These subjects are difficult to control
and can demonstrate paranoia, inappropriate violence, and feats of great
strength.
Next, call for an EMS response. Remember that Excited Delirium subjects
are at high risk for sudden death. This is
not the person that you want to place
unattended in the back of your squad car
once he or she is controlled. If the subject goes on to have a problem, it is much
better to have him in the back of an ambulance with EMS personnel in attendance. Your goal should be to have EMS
stage away from the scene but arrive as
soon as you have the subject controlled
so he or she can be evaluated. Too often,
this point is forgotten and EMS is not
called until the person collapses late in

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the control process.
These subjects will likely need rapid
and aggressive medical sedation and
evaluation at a hospital. If initiating
something like this in your community
would represent a change from how
you currently operate, you may need to
alert your EMS authority of this change
in practice and why it is a good idea.
Your risk of running into a subject
suffering from Excited Delirium is increasing, probably due to the rise in illicit stimulant use and mental illness
in our communities. Because of this, it
is inherent upon you to learn to recognize this syndrome for what it is: a
medical emergency. I encourage you
to teach yourself more about Excited
Delirium and request that your agency
provide you with appropriate training
resources.
Dr. Jeffrey Ho is a board-certified emergency
medicine physician and a Fellow of the
American College of Emergency Physicians.
He regularly consults with law enforcement
agencies on issues of in-custody death.