Special Panel Review Excited Delirium, WPSTC 2011

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Special Panel Review Excited Delirium, WPSTC 2011

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Weapons & Protective Systems
Technologies Center

Special REPORT

Special Panel Review of Excited Delirium
December 2011

This report is submitted as a result of work completed under
National Institute of Justice Cooperative Agreement Award No.
2010-IJ-CX-K005.

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

THIS PROJECT WAS SUPPORTED BY AWARD NO. 2010-IJ-CX-K005, AWARDED BY THE NATIONAL
INSTITUTE OF JUSTICE, OFFICE OF JUSTICE PROGRAMS, U.S. DEPARTMENT OF JUSTICE. THE
OPINIONS, FINDINGS, AND CONCLUSIONS OR RECOMMENDATIONS EXPRESSED IN THIS PUBLICATION ARE THOSE OF THE AUTHOR(S) AND DO NOT NECESSARILY REFLECT THOSE OF THE
DEPARTMENT OF JUSTICE.

Report Editor
Lieutenant Colonel Edward L. Hughes

THE WEAPONS AND PROTECTIVE SYSTEMS TECHNOLOGIES CENTER (WPSTC) IS PART OF THE
NATIONAL LAW ENFORCEMENT AND CORRECTIONS TECHNOLOGY CENTER (NLECTC) SYSTEM. IT
IS STAFFED BY EMPLOYEES OF THE PENNSYLVANIA STATE UNIVERSITY AND THE UNIVERSITY OF
DENVER. ALTHOUGH THE WPSTC SUPPORTS THE FEDERAL GOVERNMENT UNDER A COOPERATIVE AGREEMENT IN A VARIETY OF WAYS, NEITHER THE CENTER NOR MEMBERS OF ITS STAFF
REPRESENT THE FEDERAL GOVERNMENT, THE DEPARTMENT OF JUSTICE, OFFICE OF JUSTICE
PROGRAMS, THE NATIONAL INSTITUTE OF JUSTICE OR ANY OF ITS INTERNAL OFFICES (ISTD, OTD,
ORE, OIFS).

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Table of Contents
EXECUTIVE SUMMARY

INTRODUCTION

Background
Purpose
Panel Objectives
Perspectives
Formation of the Panel
Panel Session Agenda

SECTION 1: Excited Delirium – Does it Exist?

A Law Enforcement View of Excited Delirium
A Medical View of Excited Delirium
Conclusion

SECTION 2: Excited Delirium – Do Response Protocols Work?

General
Significance
Review of Selected Protocols
Assessments of Selected Protocols
Conclusion

SECTION 3: Excited Delirium – What Work Remains?

Terminology
Research
Stakeholder Endorsement

APPENDIX

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Applied Research Laboratory
The Pennsylvania State University

iii

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Executive Summary
This report constitutes the proceedings of a meeting of a special panel convened by the
Weapons and Protective Systems Technologies Center (WPSTC) to examine the subject
of Excited Delirium Syndrome (ExDS) and the interventions being cooperatively
developed by the law enforcement and medical communities.
The purpose of the meeting was to examine the phenomenon of “excited delirium” and
its association with the use-of-force in general and the use of CEDs in particular.
Additionally, the panel was to review, discuss, and examine related medical and other
first responder protocols. The immediate objectives of the meeting were to (1) assess
the current body of knowledge regard in excited delirium, (2) determine whether or not
existing protocols appear to mitigate the phenomenon, and (3) identify the research
questions that might remain.
The long-range goal for the panel is to arrive at some consensus on a set of
interventions that ideally (1) would reduce the likelihood of sudden and unexpected incustody deaths and (2) would not be harmful in any case, as well as to (3) identify and
qualify [characterize] the associated risks.

Excited Delirium – Does it Exist?
There is not yet a common definition of ExDS nor has its incidence been precisely
quantified across the United States, but there are growing efforts to document and
report cases regardless of outcome.
The panel examined the issue of ExDS from the law enforcement and medical perspectives. Neither community has a universal view of ExDS. However, many regard it as a
very real problem.
Medical authorities – and not just those on the panel – confirm law enforcement’s views
regarding the existence and peril of ExDS. Although there is some disagreement on
what it should be called or how it should be categorized and accounted for in medicine,
the consensus of this panel is that it certainly exists as a syndrome. Moreover, the
possibility of resultant sudden death renders it a medical emergency, requiring
immediate attention. This necessitates a coordinated response among the criminal
justice and medical communities.

Excited Delirium – Do Response Protocols Work?
The panel examined protocols, primarily considering those implemented in Lenexa,
Kansas and Seattle, Washington, as they could be defended and examined in detail
during the proceedings. Additionally, the panel considered information available from
other jurisdictions and obtained from recent studies. Not surprisingly there were many
similarities and few substantive differences.
Perhaps the most important aspect of these early and pilot protocols is the cooperative
nature of the response and the requisite training. First, and foremost, these situations
are treated as a medical crisis, not a criminal situation. This changed thinking in some
communities and has led to the development of innovative cooperative responses to
ExDS cases. These communities no longer see only law enforcement responding. All of
the protocols involve a coordinated response by dispatchers, law enforcement,
paramedics, and emergency department medical staff.
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Applied Research Laboratory
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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

While the panel acknowledged response protocols will continue to evolve and improve
with experience and research, the consensus of the panel is that overall, these
response protocols are appropriate. In the long run, they may prove to be insufficient,
but they will likely do no harm. The general response measures include:
 Clear identification of ExDS cases based on common signs and symptoms

(indicators) of the syndrome;
 Rapid control of the individual with adequate law enforcement personnel;
 Sedation by emergency medical personnel immediately after the subject is

under police control;
 Transport of the subject to a medical facility for follow-up treatment and

evaluation; and documenting the case.
It is also the consensus of the panel that use of signs and symptoms based on medical
literature provides law enforcement with more comprehensive criteria for determining a medical emergency; uniform criteria for agencies implementing such protocols
across jurisdictional boundaries; and better defensibility.
Documentation of ExDS cases should be done by emergency medical personnel and law
enforcement and embedded in their existing reporting systems (including photos, video,
audio, detailed reports, and supervisor response).
The consensus of this panel is that the detailed documentation practices included in
the Seattle and Lenexa protocols serve as models for other communities. They are
vital to better understanding the syndrome and improving the collective responses. The
implemented protocols appear to have prevented fatalities and the panel consensus is
that this will likely continue. Whether use of these protocols will reduce lawsuits is
uncertain, but they will likely help agencies defend against them, especially if they
adhere to a policy of copious documentation – both at the scene and at autopsy.

Excited Delirium – What Work Remains?
However, there are still questions that remain that can be addressed through broader
acceptance of the syndrome, systematic documentation by first responders, and
continued research. Additionally, endorsement by the National Institute of Justice is
important in generating wider acceptance in the first responder communities and the
general public.
The panel recommends the establishment of a responsible coordinating agent within
the federal government. Specifically, the NIJ could assign an office or program manager
that would be responsible to coordinate research efforts across the federal government.
Maintaining focus on the objectives of this research will require dedicated stewardship.
Specific research recommendations are contained in Section 3.

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Applied Research Laboratory
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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Introduction
Background
The Department of Justice, Office of Justice Programs (OJP) created four Technology
Centers of Excellence in 2007 to serve as specialized criminal justice technology
resources for law enforcement and other criminal justice practitioners. Each Center
provides expertise in specific technology areas and helps introduce law enforcement
technologies into practice within the criminal justice community.
The Pennsylvania State University was designated the Weapons and Protective Systems
Technologies Center (WPSTC) to support OJP efforts to enhance the safety of law
enforcement and corrections officers. These efforts include introducing into practice
safer, more effective less-lethal devices. One of the important roles of the Centers is to
assist the NIJ in identifying criminal justice technology requirements by coordinating and
conducting Technology Working Groups (TWGs) and conducting focused studies. In the
Spring of 2008, the Less-Lethal Devices TWG generated a requirement for post-incident
protocols related to the use of conducted energy devices:
There is a need for recommended post-incident protocols specifically when Conducted
Energy Devices (CED) are deployed. These include procedures that facilitate the analysis
of fluids on CED darts/probes and EMT [Emergency Medical Services – EMS] response
(including for excited delirium or in-custody death syndrome) to reduce subject risk.

Although this requirement was deleted the following Spring (2009), it was resurrected in
the Fall of 2010 as a high priority requirement:

“The goal should be to
develop a guideline
that takes advantage
of the current body of
In order to better develop a path forward, the WPSTC convened a panel of expert knowledge and the
medical and law enforcement practitioners to examine the subject of ExDS and the experiences…”
The TWG membership would like to move forward to review the work on medical and
law enforcement response to excited delirium. The goal should be to develop a guideline that takes advantage of the current body of knowledge and the experiences [of first
responders] and make that available to law enforcement and corrections in the form of
a recommended guideline.

interventions being cooperatively developed by the law enforcement and medical
communities. The meeting was conducted in Seattle, Washington in April 2011.

Purpose
The purpose of the meeting was to examine the phenomenon of “excited delirium” and
its association with the use-of-force in general and the use of CEDs in particular.
Additionally, the panel was to review, discuss, and examine related medical and other
first responder protocols. The long-range goal for the panel remains to arrive at some
consensus on a set of interventions that ideally (1) would reduce the likelihood of
sudden and unexpected in-custody deaths and (2) would not be harmful in any case, as
well as to (3) identify and qualify [characterize] the associated risks.

Panel Objectives
The immediate objectives of the April workshop, which is the subject of this report,
were to (1) assess the current body of knowledge regard in excited delirium, (2)
determine whether or not existing protocols appear to mitigate the phenomenon, and
(3) identify the research questions that might remain.

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Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Perspectives
As one might expect, there are differing perspectives regarding excited delirium or
excited delirium syndrome (ExDS).
One Perspective – Criminal Justice Practitioners
For over two decades, law enforcement and corrections officers have increasingly
reported encounters with subjects who are incoherent, naked or seem insufficiently
clothed (subjects often have elevated body temperatures), and acting in an agitated and
non-purposeful destructive manner such as smashing glass and/or windshields. Police
report that such individuals have been unresponsive to verbal directions to stop such
behavior and attempts to restrain them have been met with seemingly super-human
resistance. According to one study, an average of four officers has been required to
subdue such individuals, with a range of between three and six officers having been
reported.1 During the struggle or shortly thereafter, some individuals have suddenly
died. In one retrospective study of subjects restrained, 18 (nearly 10%) suddenly, and
unexpectedly, died (78% had a stimulant in their systems).2 In subsequent
investigations of in-custody deaths, medical examiners and law enforcement officers
have increasingly suggested that these subjects were suffering from a syndrome called
“excited delirium,” believed to be related to chronic drug abuse (with acute intoxication)
and/or mental illness (with acute exacerbation).
Another Perspective – Human Rights Advocates
Claims regarding individuals experiencing ExDS have been met with varying degrees of
skepticism, however. Some have argued that ExDS is a cover up for police brutality.
“Most of the people who die in police custody die not from drugs or some mysterious
syndrome but from police abuse,” stated Van Jones of Ella Baker Human Rights Center,
San Francisco, 1999.3 Others argue that ExDS is a TASER© International-manufactured
cover up (Figure 1). “…Canadian law enforcement and [their] American brothers and
sisters have been brainwashed by companies like TASER© International and the Institute
for the Prevention of In-Custody Deaths,” stated Michael Webster, former prison
psychologist and non-medical presenter in the 2008 Canadian Braidwood investigation.4
Figure 1 – A Protestor’s Guide It is important to point out here that the first contemporary use of the term “excited
states, “Of course, TASER
delirium” is credited to Miami medical examiners in 1985 – eight years before the
International and the police
founding of TASER©International.
refuse to acknowledge that
stun guns kill people. Instead,
they point to a fictional
disorder that they call
‘excited delirium’…”

Others maintain that ExDS does not exist at all. “I know of no reputable medical
organization – certainly not the AMA (American Medical Association) or the APA
(American Psychological Association) – that recognizes ExDS as a medical or mentalhealth condition," stated Eric Balaban of the American Civil Liberties Union (ACLU) in
1 Matthew

D. Sztajnkrycer, MD, PhD, & Amado A. Baez, MD, MSc, “Cocaine, Excited Delirium
and Sudden Unexpected Death,” EMS World, April 2005 (updated January 11, 2011).
Samuel J. Stratton, Christopher Rogers, Karen Brickett, Ginger Gruzinski, “Factors Associated
with Sudden Death of Individuals Requiring Restraint for Excited Delirium,” American Journal
of Emergency Medicine, Vol 19, No 3, May 2001.
2

3 As

attributed to Van Jones by Dr Chris Hall, Dr Chris Hall, briefing entitled, “Excited Delirium
Panel Workshop,” April 12, 2011, slide entitled, “Public conjecture on excited delirium…”
4 Testimony

of Dr Michael Webster, “In the Matter of the Thomas R. Braidwood, q.c.,
Commissions of Inquiry under the Public Inquiry Act, SBC 2007, c. 9,” May 13, 2008, p. 24
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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

2007. This view was echoed by Canadian Justice Thomas R. Braidwood in 2008: “It is, in
my view, not helpful to characterize people displaying these behaviours as suffering
from ‘excited delirium.’ Doing so implies that ‘excited delirium’ is a medical condition or
5
diagnosis, when mental health professionals uniformly reject that suggestion.” The
Braidwood report, however, merely summarizes proffered expert testimony and makes
no effort to weigh the science for or against this syndrome. Moreover, while this might
be the opinion of the ACLU and Justice Braidwood, it is important to point out that the
fact that the AMA and APA having no official position regarding ExDS is not the same as
officially stating that it does not exist. These communities do, in fact, recognize the
6, 7
diagnoses of “Delirium NOS” and “Psychosis NOS,” which ExDS would fall under.

…the fact that the
AMA and APA having
no official position
regarding ExDS is not
the same as officially
stating that it does not
exist.

The Consequences
These differing perspectives have made the disposition of resulting lawsuits very
lengthy, costly, and with much controversy – at times undermining public confidence in
law enforcement. Moreover, they have added to the polarization and mutual mistrust
of these two communities (perhaps most notably criminal justice practitioners and
human rights groups) and have inhibited objective assessments of ExDS to determine if
it is a real syndrome, and if so, what might be done to prevent, or reduce the likelihood
of, death.

The Formation of the Panel
At the direction of the Less-Lethal Devices TWG, and under the supervision of the NIJ
Program Manager for Less-Lethal Devices, Mr. Joe Cecconi, the WPSTC at Penn State
invited a diverse group of law enforcement personnel, medical practitioners, and
researchers to participate as panel members to examine ExDS (ExDS). Lieutenant
Colonel Edward Hughes (USA-Ret), the Less-Lethal Devices Program Coordinator for
WPSTC served as the panel coordinator, facilitator, and report editor.

Panel Preparation
Prior to convening, panel members were provided with the following read-ahead
material:


The Panel background, purpose, and goals as well as the objectives of the meeting.



Asia Takeuchi, MD, Terence L. Ahern, BA, Sean O. Henderson, MD, “Excited Delirium,”
Western Journal of Emergency Medicine, Volume XII, no. 1, February 2011, pp 77-83.



Gary M. Vilke, MD, Mark L. DeBard, MD, Theodore C. Chan, MD, Jeffrey D. Ho, MD, Donald
M. Dawes, MD, Christine Hall, MD, MSC, Michael D. Curtis, MD, Melissa Wysong Costello,
MD, Deborah C. Mash, PHD, Stewart R. Coffman, MD, Mary Jo McMullen, MD, Jeffery C.
Metzger, MD, James R. Roberts, MD, Matthew D. Sztajnkrcer, MD, PHD, Sean O. Henderson,
MD, Jason Adler, MD, Fabrice Czarnecki, MD, MA, MPH, Joseph Heck, DO, and William P.
Bozeman, MD, “Excited Delirium Syndrome (EXDS): Defining Based on A Review of the
Literature,” The Journal of Emergency Medicine, February 201, pp. 1–9.

5 Justice Thomas

R. Braidwood, Thomas R. Braidwood, QC, Commissions of Inquiry, Part 9, 2008.

NOS – Not Otherwise Specified.

Dr. Jeffrey D. Ho, comments on draft report provided on 11/27/2011.
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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Panel Members
Panel members were selected based on their recognized expertise in law enforcement,
less-lethal devices, emergency medicine, forensics, psychiatry, and medical research.
MEMBERS PRESENT AT MEETING
Dr. Cindy Bir (Wayne State Univ)
Officer Tom Burns (Seattle Police Dept)
Dr. Bill Bozeman (Wake Forest Univ)
Dr. David Carlbom (A/Med Dir, Seattle FD)
Dr. Michael T. Compton (G Wash Univ)
Dr. Donald Dawes (Univ of Louisville/SBPD)*
Dr. Andrew Dennis (Cook Cty Sheriff’s Dept)
Ms. Theresa G. DiMaio (Forensic Nurse)
Dr. Vincent J.M. DiMaio (Forensic Pathologist)
Sgt Fred Farris (Lenexa, Kansas Police Dept)
Dr. Chris Hall (Vancouver Island Hlth Auth)
Dr. Richard Harruff (Chief ME, King County)
Sgt Joel Johnston (Vancouver Police Dept)
Dr. Steven Karch (Pathologist/Toxicologist)
Sgt Brian Muller (LA County Sheriff’s Dept)
Dr. W. Bosseau Murray (Penn State-Anesthesia)
Officer Chris Myers (Seattle Police Dept)
Dr. Jason Payne-James (UK-Forensic Phys)
Dr. Darrell L. Ross (Valdosta State Univ)
Dr. Gary Vilke (Univ of CA San Diego)
Dr. Kent E. Vrana (Penn State-Pharmacology)
Sgt Don Whitson (Fort Collins Police Dept)
Mr. Rick Wyant (Washington State Patrol)

OTHERS PRESENT AT MEETING
LTC Ed Hughes (Penn State Univ)
Deputy Chief Clark Kimerer (Seattle PD)
Capt Jonathon Larson (Seattle FD)
Col Andy Mazzara (Dir, WPSTC Penn State)
Ms. Lynn McIntyre (Dir, Wash Crime Lab)
Mr. Norman Nedell (Medic One, Seattle FD)
Dr. Mary Williams (American Systems/JNLWD)*
OTHER PANEL MEMBERS NOT PRESENT**
Mr. Joseph Cecconi (NIJ – US Dept of Just)
Dr. Ted Chan (Univ of California San Diego)
Dr. John D’Andrea (Naval Med Res Unit)
Dr. Jeffrey Ho (Hennepin Cty Med Ctr; MCSO)*
Dr. James Jauchem (AFRL-Human Perf Wing)
Dr. Kelly Karpa (Penn State-Pharmacology)
Dr. William Kraemer (Univ of Connecticut)
Dr. Deborah Mash (University of Miami)
Mr. Graham Smith (UK- Home Office CAST)
Dr. Matt Sztajnkrycer (Mayo Clinic)
Dr. Michael Copass (Univ of Washington)

* SBPD is the Santa Barbara Police Department (California), JNLWD is the DoD Joint Non-Lethal Weapons
Directorate, MCSO is the Meeker County Sheriff’s Office, Minnesota.
** Participated via teleconference, preliminary and post-meeting discussions, and/or report review

Panel Session Agenda
Lieutenant Colonel Hughes opened the meeting and Ms. Lynn McIntyre, Director of the
Washington State Crime Lab provided welcoming remarks. Colonel Hughes then
facilitated introductions of those present, and provided guidance regarding the Panel’s
objectives. The following presentations were then made by panel members before
adjourning for the day:


An Overview of Excited Delirium by Dr. Chris Hall



Experiences with Excited Delirium by Sergeant Joel Johnston



Pharmacodynamics of Methamphetamine/Cocaine Exposure by Dr. Kent E. Vrana



Cardiac Pathology by Dr. Steven Karch



Excited Delirium by Dr. Deborah Mash (presented by Dr. Steven Karch)



The Interface Between Schizophrenia and Violence by Dr. Michael Compton



Mental Illness: Crisis Intervention for Police Officers by Dr. Michael Compton

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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

After reconvening on the second day, Deputy Chief Clark Kimerer of the Seattle Police
Department provided welcoming remarks shortly followed by additional presentations:


ECG Changes due to Extreme Exercise, Stress Hormones Changes due to Extreme
Exercise, and Sudden Unexpected Death in Epilepsy by Dr. Bosseau Murray



Experiences with Excited Delirium/Interventions (Seattle) by Officer Tom Burns



Emergency Medical Experiences with Excited Delirium Cases by Captain Jonathon
Larson, Seattle Fire Department and Dr David Carlbom, Assistant Medical Director,
Seattle Fire Department



Response to Excited Delirium Syndrome: Training Program for Police, Fire and EMS by
Sergeant Fred Farris

The panel then deliberated with Colonel Hughes facilitating the discussion until adjournment at 1700 on 13 April 2011. The following sections represent the panel’s discussions
and consensus conclusions.

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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

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Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Section 1:
Excited Delirium – Does it Exist?
There is not yet a common definition of ExDS nor has its incidence been precisely
quantified across the United States, but there are growing efforts to document and
report cases regardless of outcome. This section describes portions of the panel
discussions that endeavored to assess the current body of knowledge regarding ExDS
from a number of perspectives including law enforcement and corrections officers;
paramedics; emergency department staff; psychiatrists; and medical examiners as well
as researchers in pharmacology, cardiology, sudden death, stress physiology, forensics,
and less-lethal technologies.

A Law Enforcement View of Excited Delirium
The panel initially examined the issue of ExDS from the law enforcement perspective.
The law enforcement and corrections communities do not have a universal view of
ExDS. However, many agencies regard it as a very real problem. When relating ExDS to
those who have not seen it, law enforcement officers often provide examples and show
videos of individuals with the signs and symptoms they believe, when taken together,
constitute an identifiable syndrome. While difficult to define, ExDS is generally
composed of a varying combination of cardinal features.
Observed Indicators
When restraining individuals with signs and symptoms of ExDS, some have suddenly
died, regardless of the form of restraint used. The commonalities in such cases appear
to be extreme physical agitation or stress, followed by calming, then death. The Seattle
Police Department describes ExDS as “a state of extreme mental and physiological
excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional
strength, and endurance without apparent fatigue.”8 The Department attributes
occurrence to an underlying medical condition/crisis, likely caused by either chronic or
acute us of illicit drugs and/or mental illness.9 In the Department’s training video on
“Excited Delirium,” police officer and panel member, Chris Myers, states, “We are
seeing a lot of cocaine out there, a lot of methamphetamine and those seem to be the
primary culprits. The other factor is mental illness. It can be stimulant drugs, mental
illness, or a combination of the two.”10

The law enforcement
and corrections communities do not have a
universal view of
excited delirium.
However, many
agencies regard it as a
very real problem.

Some law enforcement agencies presume that an individual displaying certain signs and
symptoms is suffering from ExDS. The compilation of signs and symptoms has been
based on their experiences with similar cases, as well as those shared by other agencies.
Association with Use-of-Force
Law enforcement officers have attempted to restrain individuals showing signs and
symptoms of ExDS, particularly to prevent them from harming themselves, others,
and/or property.

Seattle Police Department definition from training literature provided by Officer C. Myers.

Seattle Police Department video, entitled “Excited Delirium”

Seattle Police Department video, entitled “Excited Delirium”
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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

In a Canadian study, over one million police-public interactions were investigated:
Of the 698 encounters involving use of force, 24 (3.4%) probable ExDS cases were identified based upon the presence of perceived abnormal behavior and at least six of the 10
potential clinical criteria for ExDS. Eighteen (2.7%) of the cohort manifested seven or
11
more features, including tactile hyperthermia.

Although these cases are rare, officers often encountered resistance of “exceptional
12
strength and endurance.” During or after attempted restraint, some individuals have
suddenly died. As Dallas police Senior Corporal Cotner stated in the previously cited
press report, “one minute, a person is fighting and screaming; the next minute, he's
dead.”13 Stratton et al., stated that one sign of impending cardiopulmonary arrest while
restrained from ExDS is cessation of struggle against restraints. 14 Death typically occurs
within one hour of first contact with police, and more than 75 percent who die, do so
either at the scene or during initial transport, according to a 1998 study [Ross, D.L.]15
16
cited by Matthew D. Sztajnkrycer, MD, PhD, and Amado A. Baez, MD, MSc.

Deaths from ExDS
occur even with no
police presence, but
they are much less
sensational and,
therefore, often not
newsworthy.

In the aftermath, many focus on the means of restraint as the possible cause of death,
as exemplified by the news headline, “TASERs Implicated in ExDS Deaths.”17 However,
after critics blamed a particular restraint for an unexplained death in 1982, “police
tactics were changed, but the death rate did not,” stated panel member and Seattle
police officer, Tom Burns.18 Law enforcement officers point out that ExDS-associated
deaths have occurred after the application of a variety of restraints had been employed,
implying that they can occur despite what restraint might be used – or whether one is
used at all and suggesting that the means of restraint has little or nothing to do with the
subject’s ultimate demise. It is also important to note that law enforcement presence is
not a dependent variable for death due to ExDS. Deaths from ExDS occur even with no
police presence, but they are much less sensational and, therefore, often not
newsworthy. This has led to the mistaken impression that ExDS associated death only

Christine Hall, Butler C, Kader A, et al. “Police use of force, injuries and death: prospective
evaluation of outcomes for all police use of force/restraint including conducted energy
weapons in a large Canadian city,” Academy of Emergency Medicine, 2009;16:S198–9.
11

Matthew D. Sztajnkrycer, MD, PhD, & Amado A. Baez, MD, MSc, “Cocaine, Excited Delirium
and Sudden Unexpected Death,” EMS World, April 2005 (updated January 11, 2011)
http://www.emsworld.com/article/article.jsp?id=1863.
12

Laura Sullivan, “TASERs Implicated in Excited Delirium Deaths,” National Public Radio,
February 27, 2007, http://www.npr.org/templates/story/story.php?storyId=7622314.
13

Samuel J. Stratton, Christopher Rogers, Karen Brickett, Ginger Gruzinski, “Factors
Associated with Sudden Death of Individuals Requiring Restraint for Excited Delirium,”
American Journal of Emergency Medicine, Vol 19, No 3, May 2001.
14

Ross D.L., “Factors associated with excited delirium deaths in police custody.” Mod Pathol
11: 1127–1137, 1998.
15

Laura Sullivan, “TASERs Implicated in Excited Delirium Deaths,” February 27, 2007
http://www.npr.org/templates/story/story.php?storyId=7622314
17

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide entitled “In-Custody Death History.”
18

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Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

occurs when law enforcement is present and restraining someone.
examples:

The following are



Excited Delirium-Associated Death after Pepper Spray. Officer Burns described the
December 1998 case of a partially naked, 35-year man, who was running in the
street, swinging at cars. After police had arrived, the unrestrained man accepted
ambulance transport for medical/psychiatric evaluation. However, while enroute
the man went into a rage, struggling with medical personnel and police using
pepper spray. He died at the hospital.20 Notably, the medical examiner reportedly
determined the cause of death to be "cardiac arrest, precipitated by the restraint
procedures that were employed."21



Excited Delirium-Associated Death after Handcuffing/“hog-tying.” In October 2005,
a West Palm Beach, Florida police officer found a shirtless and distraught man
stumbling on the road and attempting to stop vehicles. Told to relax, the man kept
gesticulating wildly, with vehicles stopping to avoid him. After a struggle, the officer
placed the man in a prone position, handcuffing him. Other officers arrived, helping
move the man out of the street, further restraining him, by hog-tying his legs and
hands. The man later became unconscious. Responding paramedics failed to
resuscitate him.22 The chief medical examiner for Palm Beach County determined
that the cause of death was “sudden respiratory arrest following physical struggling
restraint due to cocaine-induced ExDS.”23



Excited Delirium-Associated Death after Major Physical Struggle. Panel member
and Vancouver Police Sergeant Joel Johnston related the case of police responding
to a male subject who had a knife in a street confrontation. A foot-chase ensued,
with police grounding the subject, and multiple officers restraining him. “The
subject] was so resistive and so strong that he lifted five officers off of him at one
point,” stated Sergeant Johnston. After a protracted struggle, the subject suddenly
was quiet and went into cardiac arrest, dying at the scene. The subject suffered
from mental illness, and had alcohol and marijuana in his system.24 An autopsy
concluded the subject died from choking due to the officer's restraint and the
Coroner ruled the death accidental.

Dr. Jeffrey D. Ho, comments on draft report provided on 11/27/2011.

Seattle Police officer, Tom Burns, recorded Excited Delirium Panel, 12 April 2011. Also, Rick
Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated, slide
entitled “History.”
20

Mike Romano, “Death by Pepper Spray?” Seattle Weekly, February 17, 1999.

The case as well as video were presented by Seattle police officer, Tom Burns, recorded
panel proceedings, 13 April 2011.
22

Order Denying Plaintiff’s Motion for Summary Judgment and Granting Defendants’ Motions
for Summary Judgment, U.S. District Court for the Southern District of Florida, Lewis vs. City
of West Palm Beach, et al., Case No. 06-81139-Civ, 2008 U.S. Dist. Lexis 21587, March 18,
2008, Decided. Daniel T. K. Hurley, U.S. District Judge.
23

Sergeant Joel Johnston, recorded panel proceedings, 12 April, 2011. Sergeant Joel Johnston,
Vancouver Police Department, “Excited Delirium Update: Canadian Policing Perspective, “April
12 & 13 2011, slide 17.
24

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center


Officers often do not
immediately recognize the condition
and without imme- 
diate medical intervention, the likelyhood of death is high.

Excited Delirium Associated Death after TASER Use. According to press reports,
Dallas police found a 23 year-old, male subject in his underwear, screaming and
holding a knife on a neighbor’s porch on April 24, 2006. 25 Refusing English and
Spanish instructions, the man came at the officers with the knife. One officer fired a
TASER, which failed to connect. A second shot did, causing electrical shock.26 A third
was reportedly fired. After being handcuffed on an ambulance backboard, the
subject stopped breathing, and was pronounced dead at a hospital. The Dallas
County medical examiner attributed the death to “excited delirium.” 27
Excited Delirium Associated Death with No Police Presence. Certainly the cases
cited in the 1849 paper by Dr. Luther Bell in the Journal of Insanity had no police
presence.28 Most recently, there is the case of the Anderson University basketball
player. Anderson County Coroner Greg Shore “said [the man] had complained of
cramps and vision problems just before he collapsed on a campus basketball court
September 30, and had an ‘extremely elevated body temperature’ when he was
rushed to the emergency room of AnMed Health Medical Center. The man’s death
days later, was caused by ‘acute drug toxicity with ExDS that led to multiple organ
failure,’ Shore said.”29

A common trait in these and other similar fatalities appears to be extreme physical
exertion and/or stress experienced by the individual. Officer Burns describes other
commonalities associated with these fatalities culminating in what has been termed a
“period of peril” whereby the struggle ceases and the subject appears calm.30 All
resistance and exertion has stopped. Yet peak levels of catecholamines are reached not
during the physical activity but in those 2 to 5 minutes after cessation of the activity and
may reach ten times base levels.31 At the same time, potassium levels drop dramatically
– at times to hypokalemic levels. Both of these conditions predispose subjects to
development of cardiac arrhythmias. Officers often do not immediately recognize the
condition and without immediate medical intervention, the likelihood of death is high. 32

Laura Sullivan, “TASERs Implicated in Excited Delirium Deaths,” National Public Radio,
April 24, 2006.
25

WBAP News, “Suspect Dies After Multiple TASER Shocks,”
http://www.wbap.com/article.asp?id=205922.
26

Laura Sullivan, “TASERs Implicated in Excited Delirium Deaths,” National Public Radio,
April 24, 2006.
27

Luther V. Bell, “On a Form of Disease resembling some advanced stages of mania and fever,
but so contradistinguished from any ordinarily observed or described combination of
symptoms, as to render it probable that it may be an overlooked and hitherto unrecorded
malady,” American Journal of Insanity, October 1894.
28

As reported by Nikie Mayo in the Independent Mail on November 15, 2011.

Joel E. Dimsdale, L. Howard Hartley, Timothy Guiney, Jeremy N. Ruskin, David Greenblatt,
“Post Exercise Peril – Plasma Catecholamines and Exercise,” Journal of the American Medical
Association, February 3, 1984 (Vol 251, No 5).
30

ibid.

Seattle police officer Tom Burns, recorded panel proceedings, 13 April 2011. Rick Wyant
and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated, slide entitled
“Period of Peril.”
32

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Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

The Scope of the Problem
The exact incidence of ExDS [within the US] is “impossible to determine,” stated the
2009 Excited Delirium Task Force, commissioned by the American College of Emergency
33
Physicians (ACEP). However, the following are scattered compilations and estimates of
ExDS cases in the US:


Since 2008, the Police Department of Seattle (population of approximately 600,000)
has documented 61 cases of ExDS.34



From the first reports of ExDS-associated deaths in the early 1980s until 2005, more
than 130 cases of fatal, cocaine-associated ExDS were reported in medical and
forensic literature, according to Sztajnkrycer and Baez.35



An estimated 250 patients die in the United States each year from ExDS, about eight
to 14 percent of those who experience the syndrome, says Dr. Mark L. DeBard, a
professor of emergency medicine at Ohio State University College of Medicine and
36
chairman of the Excited Delirium Task Force. One suspects, however, that the
number of cases is much higher as one report describes findings in 100 cases.37



Stratton, et al., reported 214 cases of ExDS recorded by the Los Angeles County
Sheriff’s Department (LASD) over a six year period.38 This area includes a
population of over three million directly protected citizens in Los Angeles County.

In Canada, Vancouver Police Sergeant Joel Johnston reported colleagues encountering
subjects as early as 1991 with, what would later be recognized as, signs and symptoms
of ExDS. Today, his patrol area is in Vancouver’s Downtown Eastside, an area rampant
with drug use and mental illness (frequently in combination) – a “Petri dish” for ExDS.39
His description of clear signs and symptoms of ExDS match those observed by many US
law enforcement.40
In the 1950s, the largest psychiatric institutions in the United States were state mental
hospitals housing upwards of 5,000 patients at a time. Today, they are our city and

ACEP Excited Delirium Task Force, “White Paper Report on Excited Delirium Syndrome,”
September 10, 2009.
33

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide 27.
34

Matthew D. Sztajnkrycer, MD, PhD, & Amado A. Baez, MD, MSc, “Cocaine, Excited Delirium
and Sudden Unexpected Death,” EMS World, April 2005.
35

This is attributed to Dr Mark L. DeBard by Lisa Hoffman, “ACEP Recognizes Excited
Delirium as Unique Syndrome, Emergency Medicine News, November 2009.
36

Deborah C. Mash, Linda Duque, John Pablo, Yujing Qin, Nikhil Adi, W. Lee Hearn, Bruce A.
Hymab, Steven B. Karch, Henrik Druid, Charles V. Wetli, “Brain Biomarkers for Identifying
Excited Delirium as a Cause of Sudden Death,” Forensic Science International, 14 May 2009.
37

Sergeant Joel Johnston, recorded panel proceedings, 12 April 2011.

These features were stated by Sergeant Joel Johnston, Vancouver Police Department,
“Excited Delirium Update: Canadian Policing Perspective, “April 12, 2011, slide 16.
40

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
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41

county jails, as Dr. Michael Compton of George Washington University pointed out.
Persons with persistent mental illness once treated in long-term care facilities are now
placed on antipsychotic medications and released into the community to be treated on
42
an outpatient basis. Once released, there is no way to ensure they self-medicate.
Police officers, however, receive very little (if any) training regarding mental illnesses;
43
yet, in many ways, often become de facto mental health providers.

“You look at the
cases, you change
the names, places
and dates, and
you see the same
symptoms."

Beyond the United States and Canada, cases have been reported in Australia,44 Japan,45
and the United Kingdom.46 As Canadian emergency physician, medical researcher, and
panel member, Dr. Chris Hall states, “you look at the cases, you change the names,
places and dates, and you see the same symptoms."47
Canada, in particular, has been a leader in documenting ExDS cases. In 1998, the Ontario
Coroner’s Office published a retrospective study of 21 cases of fatal ExDS, between 1988
and 1995, in the province of Ontario, with 18 of the deaths actually occurring in police
48
custody. Over the last five years, Calgary police have documented the presence or
absence of such signs and symptoms in over 1.8 million police interactions, stated panel
member, Dr. Hall. Of the 1,269 encounters involving use of force, 37 were with subjects
presenting six or more signs and symptoms of ExDS and of these, 15 showed 9-10 signs
and symptoms.49
The Costs
Law enforcement agencies – within the US and other countries – have dealt with ExDS
cases for well over two decades. As a result, they have become increasingly aware of
the signs and symptoms, the tactical dilemma it poses for their officers, and ultimately,
its consequences. Moreover, many agencies have come to regard ExDS as a medical
crisis first, requiring a coordinated medical and law enforcement response. The costs of
ignoring the problem are significant.

Dr. Michael Compton, recorded panel proceedings, 12 April 2011.

Theresa G. DiMaio (Author) and Vincent J.M. DiMaio M.D., “Excited Delirium Syndrome:
Cause of Death and Prevention,” CRC Press, 2006, Boca Raton, FL. Pg 17.
42

Dr. Michael Compton, recorded panel proceedings, 12 April 2011.

“Corruption and Crime Commission, “The Use of TASER® Weapons by the Western
Australia Police: A Summary Report,” October 2010, p. 23.
44

Y Bunai, K Akaza, WX Jiang, A Nagai, “Fatal hyperthermia associated with excited delirium
during an arrest,” Legal Medicine Tokyo, May 19, 2008
45

“Family’s warning after ‘excited delirium’ death,” http://www.shropshirestar.com/news/
2011/07/07/familys-warning-after-excited-delirium-death/, Shropshire Star 7th July 2011
46

As attributed to Dr Chris Hall by Daryl Slade, “'Excited delirium' very real, MD says,”
Calgary Herald, August 26, 'Excited delirium' very real, MD says’, 2011.
http://www2.canada.com/calgaryherald/iphone/news/latest/story.html?id=5310862.
47

Sgt Darren Laur, “Victoria Police Department Excited Delirium and its Correlation to
Sudden and Unexpected Death Proximal to Restraint: A Review of the Current and Relevant
Medical Literature,” November 2004.
48

Dr Chris Hall, recorded panel proceedings, 12 April 2011. Also, Dr Chris Hall, briefing
entitled, “Excited Delirium Panel Workshop,” April 12, 2011, slides entitled, “Heat: Restraint”
and “Is >6 concomitant features the case definition?”
49

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center


Loss of Life. Certainly, in the view of law enforcement, the greatest cost of ignoring
this problem is the loss of life.



Personal Toll on Law Enforcement Officers. Any time that an individual dies, the
officer involved suffers personally – and often severely. “These guys went through
hell,” stated Seattle police officer, Tom Burns, referring to the officers directly
50
involved in the 1998 case in Seattle. Such cases also produce general frustration
within law enforcement organizations. Officers must prevent individuals with ExDS
from harming life and property. In doing so, there is a significant risk of in-custody
death, or what is perceived to be a “no-win situation,” as Sergeant Johnston stated.



Extensive Investigations. Investigations inevitably result when death occurs in police
custody. However, ExDS deaths have sometimes resulted in multiple investigations.
One notable case was separately investigated by the FBI, the Justice Department’s
Civil Rights Division, and the NAACP.51



Years of Costly Litigation. According to one study cited by Sztajnkrycer and Baez,
seven of 11 cases of fatal ExDS led to wrongful-death lawsuits against the agencies
involved.52 Such litigation often lasts for years. After the previously mentioned
death in West Palm Beach in 2005, the family of the subject pursued a lawsuit
against police, appealing to the US Supreme Court, which refused to examine the
case in February 2010.53



Diminished Public Confidence in Law Enforcement. “Media is selling this as a
problem with police tactics,” stated Officer Burns.54 Public doubt in law
enforcement is reflected and/or created by such sensationalist news headlines, as
“Death by Excited Delirium: Diagnosis or Cover-up?”55 and “Deaths in Custody:
Excited Delirium or Excessive Force?”56

Any time that an
individual dies, the
officer involved
suffers personally –
and often severely.

Seattle Police Officer Tom Burns, recorded HEAP proceedings 13 April 2011

Matthew D. Sztajnkrycer, MD, PhD, & Amado A. Baez, MD, MSc, “Cocaine, Excited Delirium
and Sudden Unexpected Death,” EMS World, April 2005 (updated January 11, 2011).
http://www.emsworld.com/article/article.jsp?id=1863.
51

Warren Richey, “Supreme Court rejects suit that argued excessive force by police,” Christian
Science Monitor, February 22, 2010, http://www.csmonitor.com/USA/Justice/2010/0222/
Supreme-Court-rejects-suit-that-argued-excessive-force-by-police
53

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide entitled “In-Custody Death History.”
54

Laura Sullivan, “Death by Excited Delirium: Diagnosis or Cover-up?” National Public Radio,
February 26, 2007, http://www.npr.org/templates/story/story.php?storyId=7608386
55

Tom Zeller Jr, “Deaths in Custody: Excited Delirium or Excessive Force?” New York Times,
February 27, 2007, http://thelede.blogs.nytimes.com/2007/02/27/deaths-in-custodyexcited-delirium-or-excessive-force/
56

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Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

A Medical View of Excited Delirium
“The consensus
view of the panel’s
medical experts is
that this syndrome
is indeed real.”

The consensus view of the panel’s medical experts is that this syndrome is indeed real.
That view is also shared by the National Association of Medical Examiners (NAME), the
American College of Emergency Physicians (ACEP), and other medical experts who
consider it an altered mental state falling on a continuum of delirium. It is also a
syndrome – a cluster of recognizable signs and symptoms – indicating an underlying
disorder. It is often associated with sudden death although there are many cases
annually that are successfully treated where the subject does not die. Causes for the
syndrome are not well understood, but are believed to be linked with drug use, mental
illness, certain metabolic disorders, and alterations of brain neurochemistry. While its
existence has been accepted by several medical experts, there may be several reasons
why it has not been more widely accepted. These include a 30-year gap in occurrence
(likely due to the invention of antipsychotic medication for treatment of institutionalized patients) and slow recognition (and that some observations made by first
responders and emergency medical personnel have been too lightly dismissed).
Confusion over appropriate naming has also been an issue.
The lack of broader acceptance has also been attributed to the sporadic nature of the
events, the decentralized policing and medical record systems in the United States, the
unavailability of information due to legal suits and HIPPA57 rules, the controversial
nature of death in custody without clear anatomic findings at autopsy, and the
interdisciplinary nature of the syndrome (medical examiner, law enforcement, emergency medical service, and emergency medicine).
While NAME and ACEP now recognize ExDS, the American Medical Association (AMA)
and American Psychiatric Association (APA) have no official position. This appearance of
conflict may not serve the public well. “If a police chief does not have [or appear to
have] the backing of the medical community, as much as he can understand it, basically
it goes nowhere,” stated National Institute of Justice’s Mr. Joe Cecconi.58 Any perceived
conflict, however, is less about a contrary view and more about semantics. For instance,
the AMA and the APA do recognize the existence of the diagnostic terms in the
International Statistical Classification of Diseases and Related Health Problems, 10th
Revision (ICD-10) “Delirium (due to exogenous toxic substances, F06), Delirium of mixed
origin (F05.8), and Delirium, unspecified (F05.9)” any of which this body’s definition of
ExDS fits into quite well.59 However, the exact terminology “Excited Delirium” is not
found in the ICD-10. This is analogous to the term “Crib Death” that is found in extensive
use by numerous experts and organizations that are focused on the tragic phenomenon
also known as “Sudden Infant Death Syndrome” (SIDS). Crib Death as a syndrome or
diagnosis is absent from the ICD-10 but SIDS is present. That the exact phrase of “Crib
60
Death” is absent does not mean that it does not exist.
Excited Delirium – It Exists
Referring to the question of the existence of ExDS, Dr. Christine Hall, panel member and
Canadian emergency medical physician, stated emphatically during her presentation
57

Health Insurance Portability and Accountability Act of 1996.

Mr Joe Cecconi, recorded panel proceedings, 13 April 2011.

International Classification of Disease Codes, ICD-10.

Dr. Jeffrey D. Ho, comments on draft report provided on 11/27/2011.

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Special Panel Review of Excited Delirium
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61

that “It exists.” “And, ICD-9 [International Statistical Classification of Diseases and
Related Health Problems] and ICD-10 have all of these codes for delirium, delirium druginduced, delirium agitation, [and] psycho-motor excitement. Call it what you will, it
exists.” It is also the expert medical opinion of others. For example, Dr. Asia Takeuchi, et
al., writes “ExD is a unique medical issue characterized by the acute onset of agitation,
62
aggression, distress, and possibly sudden death.” ACEP’s Excited Delirium Task Force,
63
found “that ExDS is a unique syndrome.”
Referring to ExDS, Dr. Hall further
commented that “…it was not made up by cops.”64
Altered Mental Status
Excited Delirium Syndrome “…has generally been used to describe patients displaying
altered mental status with severe agitation and combative or assaultive behavior,”
65
wrote panel member and emergency physician, Dr. Gary Vilke, et al.
This was further detailed by Dr. Hall, describing delirium in general as “a state of altered
66
level of consciousness with impairment of cognition AND perception … You get funny
67
input from your senses and you can’t think your way out of it.” “The term ‘excited
delirium’ has been used to refer to a subcategory of delirium,” wrote Dr. Vilke, et al. 68
This was again explained by Dr. Hall. Delirium is a “spectrum of activities,” as she
stated. One end of the delirium spectrum is represented by the “quiet sedated guy,
who is laying there delirious and not very busy.” At the other end of the spectrum “is
the agitated, incoherent, combative guy, who is in the throes of delirium trauma.” 69
ExDS is at the latter end of this spectrum.
Underlying Disorder
Delirium, in general, “is not a diagnosis of its own,” but rather indicates “an underlying
disorder,” stated Dr. Hall. 70 Referring to the causes of ExDS, panel member and Chair of
Penn State’s Department of Pharmacology, Dr. Kent Vrana stated, “I suspect there are
going to be many pathways to [ExDS].”71 “There is not [necessarily] going to be ‘a
disease,’” stated Dr. Vrana, referring to ExDS, “but it [(ExDS)] manifests itself as a

Dr Chris Hall, recorded panel proceedings, 12 April 2011.

62Asia

Takeuchi, MD, Terence L. Ahern, BA, Sean O. Henderson, MD, “Excited Delirium,”
Western Journal of Emergency Medicine, Volume XII, no. 1, February 2011, pp 77-83.
ACEP Excited Delirium Task Force, “White Paper Report on Excited Delirium Syndrome,”
September 10, 2009, p. 4.
63

Dr Chris Hall, recorded panel proceedings, 23 April 2011.

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 1.
65

Dr Chris Hall, brief entitled, “Excited Delirium Panel Workshop Seattle, Washington, slide 8,
entitled “Delirium.”
66

Dr Chris Hall, recorded panel proceedings, 12 April 2011.

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 1.
68

Dr Chris Hall, recorded panel proceedings, 12 April 2011.

Dr. Kent Vrana, recorded panel proceedings, 13 April 2011.
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72

syndrome,” meaning that it will present itself as several clinically recognizable
features, signs, and symptoms.
While ExDS may be considered only a syndrome and not a specific disease, identifiable
neurochemical abnormalities are always identified when sought. Measureable changes
in dopamine transporters and sigma receptors have always been found when the brains
of these individuals are examined. But examination is so uncommon, that this knowledge has not been widely disseminated.73

“[ExDS] may be
identified by the
presence of a
distinctive group
of clinical and
behavioral
characteristics.”

Excited delirium syndrome “may be identified by the presence of a distinctive group of
74
clinical and behavioral characteristics,” reported the ACEP Excited Delirium Task Force.
Signs and symptoms of ExDS were compiled from medical literature by the Task Force,
matching many of those observed by law enforcement officers in the field.
Sudden Death
Delirium has been long been associated with sudden death. In 1849, Dr. Luther Bell, a
psychiatrist at Massachusetts’ McLean Asylum for the Insane, described a clinical
condition in which approximately 30 violent and aggressive patients suddenly died.75 It
eventually became known as acute exhaustive mania or “Bell’s Mania” the signs and
symptoms of which are thought to be similar to those of ExDS.76 More recently, the
British Columbia Medical Association published that “hospital mortality rates skyrocket”
with perioperative (period around surgery) delirium.77
While the degree to which ExDS ends in sudden death is unknown, some have estimated
its occurrence. “A small percentage of patients with ExDS progress to sudden cardiopulmonary arrest and death,” wrote Dr. Vilke, et al. They also stated that “a published
observational study [Stratton, et al.] suggests that the incidence of death among
patients manifesting signs and symptoms that may be consistent with ExDS is less than
ten percent.”78 As previously mentioned, Dr. Mark L. DeBard, Chairman of the Excited

Dr. Kent Vrana, recorded panel proceedings, 13 April 2011.

Theresa G. DiMaio (Author) and Vincent J.M. DiMaio M.D., “Excited Delirium Syndrome:
Cause of Death and Prevention,” CRC Press, 2006, Boca Raton, FL. Pp 7-8.
76

This is attributed to Dr Chris Hall, recorded panel proceedings, 12 April 2011. She stated,
“The B.C. Medical Association just published an article in our little journal about the hazards
of perioperative in delirium and that in the hospital mortality rates skyrocket…”
77

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 3.
78

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Special Panel Review of Excited Delirium
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Delirium Task Force, estimates that about eight to 14 percent of those who experience
the syndrome die.79
Postmortem assessments have provided some information on ExDS fatalities. The
profile of individuals having died after ExDS was described by Dr. Vilke, et al.: “More
than 95% of all published fatal cases involve men at a mean age of 36 years.”80 The ExDS
fatalities have been summarized by Dr. Asia Takeuchi, et al:
It appears that in all cases, victims died of either respiratory arrest or fatal cardiac
dysrrhythmia. Diagnoses were supported by postmortem exams showing pulmonary
and cerebral edema with nonlethal self-inflicted injuries. The few who live long enough
to be hospitalized often succumb to disseminated intravascular coagulation, rhabdomyolysis and renal failure. These fatal cardiopulmonary changes are thought to be the
result of increased catecholamine stress on the heart, myocardial hypertrophy, micro81
angiopathy and fatal arrhythmias. The proposed cause of these changes is debated.

The hypothesis of chronic stress leading to deleterious anatomic changes of the heart
(e.g., left ventricular hypertrophy) with an increased incidence of mortality during some
episodes of acute stress from extreme exercise, has several corollaries in a variety of
medical conditions. Furthermore, as a general principle, “sudden death is not tied to
one type of disease,” stated panel member and medical researcher, Dr. W. Bosseau
Murray. It can also be, in certain cases, attributed to stress on top of an underlying, but
unknown (in the sense of “not yet diagnosed”) medical condition, such as cardiac
anatomic or conduction abnormalities. “People with a higher degree of chronic stress
(with long term higher levels of catecholamines) tend to have higher mortality rates
during acute episodes of severe stress,” stated Dr. Murray. “There are some people with
a chronic heart condition who have a daily risk of dying given episodes of severe
exercise and/or stress.” 82
Dr. Murray provided epilepsy as one example. Those with epilepsy have a four-fold
increase in incidence of death, compared to the rest of the population.83 Epileptic
seizures produce a stress similar to exercise or a physical struggle. While such sudden
deaths are attributed to cardiac deaths, the exact mechanisms, pathways, and causes
are unknown. For instance, while the syndrome called SUDEP (sudden death during
epilepsy) might explain some of the sudden deaths, it is not the mechanism in all such
deaths. A second example is the sudden death that has also occurred with subclinical
hyperthyroidism and the consequent long term increase in the effects of
84
catecholamines.

This is attributed to Dr Mark L. DeBard by Lisa Hoffman, “ACEP Recognizes Excited
Delirium as Unique Syndrome, Emergency Medicine News, November 2009.
79

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 3.
80

Asia Takeuchi, MD, Terence L. Ahern, BA, Sean O. Henderson, MD, “Excited Delirium,”
Western Journal of Emergency Medicine, Volume XII, no. 1, February 2011, pp 77-83.
81

All information in this paragraph is from Dr Bosseau Murray, recorded panel proceedings,
13 April 2011 and subsequent discussions with Dr. Steven Karch.
82

Study conducted over 40 years in Finland as published in the New England Journal of
Medicine (Dec 2010) and reported in Science News, January 29, 2011.
83

All information in this paragraph is from Dr Bosseau Murray, recorded panel proceedings,
13 April 2011 and subsequent discussions with Dr. Steven Karch.
84

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Pathophysiology
The actual pathophysiology of ExDS is complex and poorly understood. Generally, it is
associated with drug use; psychiatric illness; metabolic disorders; and/or intra-cerebral
85
events.
“The majority of [ExDS] cases involve stimulant abuse, most commonly cocaine,
although methamphetamine, PCP, and LSD have also been described,” wrote Dr. Vilke,
et al. “As more attention is drawn to ExDS as a recognized entity, it is likely that other
drugs of abuse may be identified as also etiologic,” as they further stated. Other such
drugs possibly causing ExDS (variants of excitement and delirium) are:


Phencyclidine, benzoylecogonine, marijuana, lithium, methylphenidate HCl,
haloperidol, lidocaine, and valproic acid;86



Some Over-the-Counter Drugs: These include dimenhydrinate and diphenhydramine;



Tricyclic antidepressants (TCAs); and



Methylenedioxypyrovalerone, the most commonly identified active ingredient
in “bath salts.” “It is smoked, mixed with food, or injected,” stated Dr. Hall. The
effects are prolonged with methamphetamine use and have been reported to
last as long as three days.88 In late April 2011, panel member, Sergeant Don
Whitson of the Fort Collins, Colorado Police Department, reported that two
individuals appeared to have experienced ExDS after ingesting bath salts (and
variants thereof).89

The Perfect Storm. Excited delirium syndrome is perhaps more aptly described as a
confluence of events caused by psychoactive stimulant abuse. This description is based
on research conducted on the pharmacodynamics (what drugs do to the body) and
pharmacokinetics (what the body does with these drugs) of cocaine and methamphetamines. These two drugs differ in structure and composition and their effects and
half-lives differ, pointed out Dr. Kent Vrana, Chair of Department of Pharmacology at
Penn State’s College of Medicine. Their effects and half-lives also differ. Notably, the
effects of methamphetamines last longer – about 4.5 hours compared to one hour for
cocaine.90 On the other hand, the drugs have similar underlying mechanisms of action
(which are also shared with other stimulant/psychoactive – legal and illegal – drugs).
These possible causes are from Dr Chris Hall, brief entitled, “Excited Delirium Panel
Workshop Seattle, Washington, “ slide 31, entitled “Excited delirium: understanding
physiology/ differential diagnoses.”
85

Dr Kent E. Vrana; Elliot S. Vesell, Professor and Chair of Pharmacology; Annie Sopic,
PharmD Candidate; Dr Kelly Karpa, Associate Professor of Pharmacology, brief entitled,
“Pharmacokinetics and Pharmacodynamics of Methamphetamine and Cocaine,” 12 April
2011.
86

These possible causes are from Dr Chris Hall, brief entitled, “Excited Delirium Panel
Workshop Seattle, Washington, “ slide 31, entitled “Excited delirium: understanding
physiology/ differential diagnoses”
87

Dr Chris Hall, recorded panel proceedings, 23 April 2011.

Sergeant Don Whitson, email dated, 28 April 2011.

Dr Kent E. Vrana; Elliot S. Vesell, Professor and Chair of Pharmacology; Annie Sopic,
PharmD Candidate; Dr Kelly Karpa, Associate Professor of Pharmacology, brief entitled,
90

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For instance, both prevent catecholamine uptake to a similar degree and both affect
dopamine metabolism. Further, published research shows that most of the surplus
catecholamine circulating after the use cocaine (and presumably methamphetamine) is
norepinephrine overflow from the heart, not epinephrine from the adrenal glands
(which may be minimal).91
Both of these drugs also have three common characteristics, causing a “perfect storm”
in terms of ExDS, hypothesized Dr. Vrana:92


Behavioral effects necessitating police and medical intervention;



Physical restraint because of unresponsive and uncontrollable behavior;



A surge of catecholamine "fight-or-flight" hormones released by the adrenal
glands in response to stress, seemingly contributing to superhuman strength
and endurance.

“These pathophysiological responses, when expressed on an underlying genetic predisposition to cardiac arrhythmias, may precipitate sudden cardiac death,” Dr. Vrana
also stated.93 Interesting is the increasing focus on channelopathies, particularly those
that control the entrance and exit of calcium from the cells with each heartbeat or nerve
impulse.
Underlying Cardiac Abnormalities. Prior chronic drug use may predispose individuals to
sudden death in the event of physical stress. “Cocaine and methamphetamine cause
concentric enlargement of the heart,” stated panel member and cardiac researcher, Dr.
Steven Karch. “Concentric enlargement of the heart makes it electrically unstable and
prone to arrhythmias,” Dr. Karch further elaborated. Cocaine and methamphetamine
result in the buildup of “perivascular fibrosis,” which is essentially scar tissue in the
heart. Thus, when individuals engage in some physical stress requiring increased cardiac
output, the intramyocardial vessels that run through their hearts have reduced abilities
to do so, because they are encased in the equivalent of “concrete or elastic bands,” as
Dr. Karch phrased it. Also, this scar tissue “does not conduct electricity at all.
Depolarization will occur and it will hit this scar tissue, and bounce right off. Pretty soon
you'll have electrical chaos,” stated Dr. Karch.94
Psychiatric Illness. “Ten to twenty percent of the excited delirium cases are purely
psychiatric,” estimated panel member and medical examiner, Dr. Vincent DiMaio.95 “The
literature on ExDS frequently cites abrupt cessation of psychotherapeutic medications
“Pharmacokinetics and Pharmacodynamics of Methamphetamine and Cocaine,” 12 April
2011, slide 30 entitled, “Stimulant Comparison.”
Steven B. Karch, “Stimulant abuse and sudden cardiac death,” in Kroll MW and Ho JD,
editors, TASER©conducted electrical weapons: physiology, pathology, and law. New York:
Springer Science+Business Media; 2009.
91

Dr Kent Vrana, recorded panel proceedings, 13 April 2011.

Also, Dr Kent E. Vrana, Elliot S. Vesell Professor and Chair of Pharmacology; Annie Sopic,
PharmD Candidate; Dr Kelly Karpa, Associate Professor of Pharmacology, brief entitled,
“Pharmacokinetics and Pharmacodynamics of Methamphetamine and Cocaine,” 12 April
2011, slide 32 entitled, “Working Hypothesis.”
93

All information in this paragraph is from Dr Steven Karch, recorded panel proceedings, 12
April 2011.
94

Dr. Vincent DiMaio, recorded panel proceedings, 12 April 2011.
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as a cause,” wrote Dr. Vilke, et al. “Less commonly, persons with new-onset psychiatric
disorder, particularly those with manic or psychotic features, will present with ExDS.”96
Of those psychiatric-related ExDS cases, “it’s nearly always those suffering
97
schizophrenia,” stated panel member and forensic nurse, Theresa DiMaio. To some
degree, it is because of dopamine errors in the brain, similar to those experienced by
98
cocaine users. Another factor was explained by Dr. DiMaio:
Norepinephrine (catecholamine, “fight or flight” hormone) and epinephrine (adrenaline)
levels in patients suffering schizophrenia are elevated. So, they are starting at a higher
plateau than the general population. In addition, when they are stimulated, their
reaction to a stimulus – psychological, physical, or even chemical – is to put out even
99
higher levels of norepinephrine and epinephrine than in the general population. It is
important also to note that plasma catecholamine concentrations in those afflicted with
schizophrenia are under direct genetic control which means that genetic polymorphisms
100
could certainly play a role in the occurrence of ExDS.

Metabolic Disorders. “Diabetic hypoglycemic reactions have been associated with
outbursts of violent behavior and an appearance of intoxication,” wrote Dr. Vilke, et
al.101 Also, “thyroid storm may contribute to excited delirium,” stated Dr. Vrana.102 Dr.
Hall also pointed out that alcohol withdrawal may contribute as well.103
Intra-cerebral Events. Intra-cerebral hemorrhaging and encephalitis have also been
associated with violent outbursts.104 These events are surely rare when compared to
the known neurochemical alterations seen in the brains of chronic stimulant abusers.105

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 5.
96

Ms. Theresa DiMaio, recorded panel proceedings, 12 April 2011.

Dr Chris Hall, brief entitled, “Excited Delirium Panel Workshop Seattle, Washington, “slide
37, entitled “Mental Illness.”
98

Dr. Vincent DiMaio, recorded panel proceedings, 12 April 2011.

Mercedes Zumárragaa, Ricardo Dávilaa, Nieves Basterrecheb, Aurora Arruea, Biotza
Goienetxeab, María I. Zamalloaa, Leire Erkorekac, Sonia Bustamantec, Lucía Inchaustic,
Miguel A. González-Torresc, José Guimónd, “Catechol O-methyltransferase and monoamine
oxidase A genotypes, and plasma catecholamine metabolites in bipolar and schizophrenic
patients,” Neurochemistry International, Volume 56, Issues 6–7, May–June 2010, Pages 774–
779.
100

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 5
101

105

Dr. Steven Karch comments on draft report provided on 11/10/2011.

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Wider Acceptance in the Medical Community
As previously discussed, the American Psychiatric Association (APA) has not recognized
ExDS, nor is it mentioned in its Diagnostic and Statistical Manual of Mental Disorders.
Moreover, the term is not in the World Health Organization’s International Classification
of Diseases (ICD-9). The panel attributed a number of contributing factors.


Thirty-Year Gap in Occurrence. As mentioned, in 1849 Dr. Bell characterized the
violent and aggressive mania of psychiatric patients, who often died. However, a
30-year gap in its occurrence was addressed by both the DiMaio text and Vilke et al:
The incidence of the problem behaviors and sudden death described in the 1800s
seemed to decline drastically by mid-1950s. This has been largely attributed to the
advent of modern antipsychotic pharmaceutical therapy used for these patients
with severe behavior issues. In the 1980s, there was a dramatic increase in the
number of reported cases with behavior similar to an uncontrolled psychiatric
emergency. Whereas some seemed to be unchecked psychiatric disease, most of
these cases were found to be associated with the introduction and abuse of
cocaine in North America. 106, 107



Decline in Mental Institutions. One of the unintended consequences of the
decline of state mental institutions has been that these patients have effectively been “moved from mental hospitals (housing upwards of 5,000 at a time) to
our city and county jails,” Dr. Compton pointed out. Persons with persistent
mental illness once treated in long-term care facilities are now treated on an
outpatient basis, placed on antipsychotic medications, and released into the
community. There is no effective way to ensure they self-medicate.



Observed Primarily by First Responders. While most syndromes present themselves
to physicians, Dr. Vrana stated that symptoms of ExDS are “a series of behaviors
and characteristics that manifest themselves with the law enforcement folks.” 109
This was further reinforced by panel member and practicing psychiatrist, Dr.
Michael T. Compton:

One of the unintended
consequences in the
decline of state mental
institutions … has been
that these patients
have effectively been
 Slow Recognition. The term “excited delirium” was coined in 1985 by C.V. Wetli and
“moved from mental
D. A. Fishbain in their publication, “Cocaine-induced psychosis and sudden death in
108
recreational cocaine users.” Only in recent years has it been accepted by portions hospitals … to our city
of the medical community.
and county jails.”

…one domain or cluster of signs/symptoms in schizophrenia would include
aggression, hostility, and agitation. In my world, those are fairly rare…In the world
of law enforcement officers, this is very different. They are more likely to see this
cluster of signs/symptoms just because of the nature of their work.110


Idiomatic Arguments. What matters most to first responders (including law enforcement) is what something is, not what something is called. “For more than 150 years,

Theresa G. DiMaio (Author) and Vincent J.M. DiMaio M.D., “Excited Delirium Syndrome:
Cause of Death and Prevention,” CRC Press, 2006, Boca Raton, FL. Pp 7-8.
106

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 3.
107

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 3.
108

109

Dr Kent Vrana, recorded panel proceedings, 13 April 2011.

110

Dr Michael Compton, recorded panel proceedings, 12 April 2011.
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there have been case reports that do not use the exact term ‘excited delirium,’ yet
describe a similar constellation of symptoms and features,” wrote Dr. Vilke et al.111
The panel also noted the different terms for describing the signs/symptoms
associated with ExDS. “When [medical practitioners] talk about ‘excited delirium,’
it’s the same thing that [psychiatrists] call an ‘acute psychotic episode,’” stated Dr.
112
DiMaio.
“What we are doing here is interchanging delirium and acute
psychosis,”113 continued forensic consultant, Dr. Jason Payne-James of the United
Kingdom. Also, panel member and psychiatrist, Dr. Michael T. Compton stated,
“Clearly, we are talking about the same phenomenon, but psychiatrists in an inpatient psychiatric setting typically do not use the term ‘excited delirium.’ We call it
‘acute psychotic agitation.’” 114

What matters most
to first responders is
what something is,
not what something
is called.

In post meeting discussions, Dr. Matthew Sztajnkrycer was not convinced that the
two are inter-changeable. He argued that they represent very different entities
which should not be confused. “Delirium refers to waxing and waning in consciousness, and reflects an underlying medical condition. Psychosis is a loss of reality and
reflects a psychiatric condition. The key point is that delirium has an underlying,
possibly treatable medical cause that must be found. Delirium is a medical/organic
emergency while psychosis is a psychiatric/functional emergency. The management
is very different. An antipsychotic would be the treatment of choice for acute
psychosis but may be harmful for ExDS. Likewise, missing thyroid storm or
hypoglycemia and assuming simply a functional psychosis would be harmful.”115
Additionally, present medical literature uses different terms for signs/symptoms
associated with ExDS. The Diagnostic and Statistical Manual of Mental Disorders –
Fourth Edition has multiple references to delirium and agitation. The International
Classification of Diseases also contains the following codes, which match the
signs/symptoms of ExDS: 116










296.00S
293.1J
292.81Q
292.81R
307.9AD
780.09E
799.2AM
799.2V
799.2X

Manic Excitement
Delirium of Mixed Origin
Delirium, drug induced
Delirium, induced by drug
Agitation
Delirium
Psychomotor Excitement
Psychomotor Agitation
Abnormal Excitement

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 2
111

112

Dr. Vincent DiMaio, recorded panel proceedings, 12 April 2011.

113

Dr. Jason Payne-James, recorded panel proceedings, 12 April 2011.

114

Dr Michael Compton, recorded panel proceedings, 12 April 2011.

115

Dr. Matthew Sztajnkrycer comments on draft report provided on 11/10/2011.

This was stated by Dr Chris Hall, brief entitled, “Excited Delirium Panel Workshop Seattle,
Washington, “slide 9, entitled “Excited Delirium.” It was also stated Gary M. Vilke, et. al.,
“Excited Delirium Syndrome (EXDS): Defining Based on A Review of the Literature,” The
Journal of Emergency Medicine, February 2011, p. 3.
116

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Conclusion
Medical authorities – and not just those on the panel – confirm law enforcement’s views
regarding the existence and peril of ExDS. Although there is some disagreement on
what it should be called or how it should be categorized and accounted for in medicine,
the consensus of this panel is that it certainly exists as a syndrome. Moreover, the
possibility of resultant sudden death renders it a medical emergency, requiring
immediate attention. This necessitates a coordinated response among the criminal
justice and medical communities.

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Section 2:
Excited Delirium – Do Response Protocols Work?
General
In referring to ExDS and how to best respond, Mr. Joe Cecconi of the National Institute
of Justice stated, “My goal is to come up with a recommended response – especially for
how law enforcement should respond. If we can recommend only guidelines that might
yield a treatment in the future, then that fits in well within this program.”117 This
section describes portions of the panel discussions that reviewed some of the existing
response protocols and determine whether or not they appear to mitigate the
phenomenon.

Significance
Protocols for treating ExDS were described in the 2009 White Paper Report on Excited
Delirium Syndrome by the American College of Emergency Physicians’ Excited Delirium
Task Force. That task force included many of the current panel members. The current
NIJ Panel assessment of implemented protocols is significant for the following reasons:


It was a broad interdisciplinary assessment of protocols currently in use by experts
in emergency medicine, medical research (cardiology, pharmacology, pathology,
stress physiology, and psychiatry), forensics, and law enforcement; and



It was conducted under the auspices of the National Institute of Justice. Speaking
from a local law enforcement perspective, panel member, and Lenexa, Kansas
Police Sergeant Fred Farris stated, “The stamp from NIJ goes a long way in terms of
credibility.”118

Review of Selected Protocols
The panel examined protocols, primarily considering those implemented in Lenexa,
Kansas and Seattle, Washington, as they could be defended and examined in detail
during the proceedings. Additionally, the panel considered information available from
other jurisdictions and obtained from recent studies. Not surprisingly there were many
similarities and few substantive differences.
Bottom Line – Saving Lives
Police Departments represented at the panel meeting reported that these protocols
have helped save the lives of individuals with ExDS. Officer Burns cited two individuals
who survived after being treated as described in the Seattle protocol.119 Seattle is now
documenting these “saves” as part of its reporting systems. Sergeant Farris showed a
video of an individual with ExDS surviving after a combined medic and law enforcement
response in Lenexa, Kansas.

117

Mr. Joe Cecconi, recorded panel proceedings, 13 April 2011.

118

Sergeant Fred Farris, recorded panel proceedings, 13 April 2011.

The two individuals surviving excited delirium were cited by Rick Wyant and Tom Burns,
brief entitled “Excited Delirium: The First Response,” undated, slides 30-31 entitled, “Success
through Cooperation”
119

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Additionally, such initiatives have gained international attention, even though the
evidence is largely based on anecdotal evidence and case events. After an individual
with ExDS died in UK police custody, his family publicly stated “more could have been
done to prevent Jason’s death, whether that be through proper recognition of the
symptoms and potential life threatening effect of a potential ExDS scenario and/or
speedier action to summon medical assistance.” The family also stated, “The American
and Canadian authorities are far more advanced in dealing with excited delirium…”120
While this statement is certainly debatable with regard to a broad national approach,
there are jurisdictions in both countries that appear to be further advanced in their
understanding of how to best deal with these situations.
Coordinated and Cooperative Effort

“ExDS is a medical
problem masquerading as a police call.”

Perhaps the most important aspect of these early and pilot protocols is the cooperative
nature of the response and the requisite training. First, and foremost, these situations
are treated as a medical crisis, not a criminal situation. “[The subjects] are acting out,
they are violent, it looks like it’s a hard core, law enforcement problem,” stated panel
member and Seattle police officer, Chris Myers, referring to first impressions of
individuals with ExDS.121 However, as stated by panel member and Vancouver Police
Sergeant Joel Johnston, “ExDS is a medical problem masquerading as a police call.”122
Sergeant Farris added, “This is medical crisis with a priority over criminal behavior.”
This changed thinking in some communities and has led to the development of
innovative cooperative responses to ExDS cases. These communities no longer see only
law enforcement responding. The first response is really a multi-disciplinary effort.123
Some communities have protocols enabling coordinated response training with
dispatchers, emergency medical personnel, as well as law enforcement. Such protocols
have been reported in Dallas, Texas;124 Lenexa, Kansas; Miami-Dade County, Florida;125
San Jose, California;126 Seattle, Washington; and the State of Wisconsin Department of

“Family’s warning after ‘excited delirium’ death,” 7 July 2011, http://www.shrop
shirestar.com/news/2011/07/07/familys-warning-after-excited-delirium-death/
120

Seattle Police Department, “Excited Delirium” training video, 2007. Can be viewed at
http://blutube.policeone.com/videos/931151440001-excited-delirium-discussion-andexplanation/
121

Sergeant Joel Johnston, recorded panel proceedings, 12 April, 2011. Sergeant Joel
Johnston, Vancouver Police Department, “Excited Delirium Update: Canadian Policing
Perspective, “April 12, 2011, slide
122

123

Officer Tom Burns, recorded panel proceedings, 13 April 2011

Tom Zeller, “Deaths in Custody: Excited Delirium or Excessive Force?” New York Times,
February 27, 2007, http://thelede.blogs.nytimes.com/2007/02/27/deaths-in-custody-exciteddelirium-or-excessive-force/
124

David Kleinman, NREMT-P, “Excited Delirium,” EMS World, March 2009 (Updated:
January 12th, 2011) http://www.emsworld.com/print/EMS-World/Excited-Delirium/1$9165,
125

Policeone.com “A look at San Jose PD's new excited delirium protocol,” June 11, 2007,
(from Force Science News) http://www.policeone.com/edp/articles/1269555-A-look-at-SanJose-PDs-new-excited-delirium-protocol/
126

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127

Corrections.
Such protocols are also seen as having broad applicability. “The hope is
that this training will be provided through the regional training academy and available
to all LEOs (law enforcement organizations) in the county,” states Sergeant Farris,
128
referring to Lenexa, Kansas and the surrounding Johnson County.
Training in such
protocols has also been reported in the Calgary Police Service, Halifax Regional Police,
Royal Canadian Mounted Police, Ontario Provincial Police, Ontario Police College,
Edmonton Police Service, and Vancouver Police Department, and various ExDS training
programs across Canada. 129, 130 All of the protocols involve a coordinated response by
dispatchers, law enforcement, paramedics, and emergency department medical staff.

Assessment of Selected Protocols
The common protocol steps – identify ExDS, rapidly control, sedate and transport to a
medical facility – generally adhere to the White Paper Report on Excited Delirium
Syndrome by the American College of Emergency Physicians’ Excited Delirium Task
Force. While the panel acknowledged response protocols will continue to evolve and
improve with experience and research, the consensus of the panel is that overall, these
response protocols are appropriate. In the long run, they may prove to be insufficient,
but they will likely do no harm. Departments have also established documentation
practices for these protocols, not described in the White Paper, but which this panel
also recommends.
 Clear identification of ExDS cases based on common signs and symptoms

(indicators) of the syndrome;
 Rapid control of the individual with adequate law enforcement personnel;
 Sedation by emergency medical personnel immediately after the subject is

under police control;
 Transport of the subject to a medical facility for follow-up treatment and

evaluation; and documenting the case.

Figure 2 – Quick Reference
Card developed by panel
(side 1).

During a two-week period following the meeting, the panel arrived at a general
consensus for a quick reference card for first responders that includes these steps
(Figure 2).
Identify
The goal of the identification portion of these protocols is the “recognition of common
signs/symptoms (indicators) of ExDS [in a subject],” stated Sergeant Farris. Thus, most
protocols require likely first responders to be trained to recognize its signs and
symptoms. When receiving calls, dispatchers are trained to ask key questions to
determine if an individual is exhibiting any signs and symptoms of ExDS. If it is
A video of Wisconsin Corrections apparent protocol for excited delirium can be viewed at
“Excited Delirium” by Gary Klugiewicz, http://blutube.policeone.com/police-cool-stuffvideos/935675120001-excited-delirium/
127

128

Sergeant Fred Farris, recorded panel proceedings, 13 April 2011.

Daryl Slade “‘Excited delirium’ now part of Calgary police training,” Calgary Herald, August
24, 2011 http://www.calgaryherald.com/Excited+delirium+part+Calgary+police+training/
5301614/story.html#ixzz1WBRlvq00
129

Sergeant Joel Johnston, Vancouver Police Department, briefing entitled, “Excited Delirium
Update: Canadian Policing Perspective,” April 12, 2011, slide 13.
130

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suspected, dispatchers will simultaneously contact fire department/paramedic
representatives who ask medical questions. Together, they determine if a joint
response is necessary. Time is obviously crucial to this process. Dispatchers also will
relay critical information to law enforcement officers responding to the incident.
Law enforcement officers are trained to distinguish between rowdy bar behavior –
regarded as relatively self-controlled and modifiable – and ExDS, seen as
uncontrolled/unresponsive behavior. “We are not expecting officers to become
diagnosticians or medics,” stated Officer Myers, “but we do want [police officers] to be
familiar with the different signs and symptoms of ExDS, as a medical crisis.” Officers are
trained to assess from a relatively safe distance, and if they suspect an ExDS case, call
for paramedics and law enforcement back up. While there are some differences in the
indicators used by different jurisdictions, most of these differences are not substantive
(see Table 2-1).
Lenexa131
 Violent resistance/struggling

Vancouver132

Seattle133

 Extremely aggressive or violent
behaviour

 Extreme agitation,
disorientation

 Constant or near constant
physical activity

 Violence toward others

 Inappropriate shedding of
clothing

 Naked or inappropriately
clothed for environment

 Profuse sweating

 Hyperthermia (overheating),
sweating, seeking water,
inappropriate or no clothing

 Superhuman strength

 Unexpected physical strength

 Extreme aggression toward
objects

 Bizarre and/or aggressive
behavior

 Hyperthermia
 High core body temp
 Does not appear to tire despite
heavy physical exertion
 Self inflicted injuries

 Tolerant to pain

 Insensitivity to pain

 Subject does not respond to
police presence
 Talking incoherently

 Rapid breathing

 Screaming

 Shouting or keening (animal
noises)

 Yelling

 Panic

 Paranoia

 Lid lift (eyes wide open)
 Paranoia

 Dilated pupils
 Skin discoloration

 Attraction to or destruction of
glass or reflective objects

 Sudden tranquility

Table 2-1. A Comparison of ExDS Indicators from existing protocols.

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide entitled, “Training.”
131

Sergeant Joel Johnston, , “Excited Delirium Update: Canadian Policing Perspective,” April
12 & 13 2011, slide 16.
132

133

These are from the Seattle Police Department, “Excited Delirium” training video, 2007.

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The 2009 White Paper Report on Excited Delirium Syndrome recommends that “[law
enforcement officers] should be trained to recognize and manage subjects with
ExDS.”134 In keeping with this recommendation, the Seattle and Lenexa Police
Departments train officers and dispatchers to recognize ExDS signs/symptoms. Also,
these departments have correctly coordinated police and emergency medical responses
for such cases. The panel provides the following:


Use signs/symptoms (indicators) based on those in the medical literature.135 As
mentioned, Seattle and Lenexa, Kansas police departments provide signs/
symptoms generally, but not uniformly, matching those found in the medical
literature. For example, keening – unintelligible, animal-like noises – is not
found in the medical literature, but is included in Seattle’s signs/symptoms. It is
the consensus of the panel that use of signs/symptoms based on medical
literature provides law enforcement with more comprehensive criteria for
determining a medical emergency; uniform criteria for agencies implementing
such protocols across jurisdictional boundaries; and better defensibility.
Following the meeting, the panel arrived at a general consensus for a revised
list of indicators (below) for the quick-reference card (Figure 3).
















Extremely aggressive or violent behavior
Constant or near constant physical activity
Does not respond to police presence
Attracted to/destructive of glass/reflective
Attracted to bright lights/loud sounds
Naked/inadequately clothed
Attempted “self-cooling” or hot to touch
Rapid breathing
Profuse sweating
Keening (unintelligible animal-like noises)
Insensitive to/extremely tolerant of pain
Excessive strength (out of proportion)
Does not tire despite heavy exertion

Recognize that indicators (signs/symptoms) will not present uniformly. While
all protocols should have a uniform list of indicators, individuals with ExDS will
not uniformly exhibit them. As explained by Dr. Vilke, et al:

Figure 3 – Quick Reference Card
developed by panel (side 2).
Figure 4– Quick Reference Card
developed by panel (side 2).

“Due to varied underlying medical conditions that may generate ExDS, there
is also variation in the specific symptom cluster [cluster of signs]. As in any
disorder that affects mental status, there is no assumption that each
subject’s presentation will have the same clinical presentation however, all
patients with ExDS present delirious with evidence of psychomotor and
physiologic excitation.” 136
134

ACEP Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p. 9.

The signs/symptoms are based on medical literature are: extremely aggressive or violent
behavior, constant/near constant physical behavior, unresponsive to police presence,
attracted to glass and reflections, attempting destruction, attracted to bright lights and loud
sounds, naked or inadequately clothed, hot to the touch and attempted self cooling, profuse
sweating, rapid breathing, keening – unintelligible, animal-like noises, extremely intolerant of
pain, excessive and seemingly disproportionate strength, untiring despite heavy exertion.
135

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 5.
136

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Control
In these protocols, control at the scene is accomplished by law enforcement. There is
growing recognition that ultimately, medical intervention will be needed for subjects
experiencing ExDS. Law enforcement must facilitate this medical intervention,
particularly if such individuals are violent. At the scene, Seattle police officers are
instructed to do the following:


Ensure Adequate Back-up. Prior to arrival of paramedics, officers may attempt to
de-escalate, using verbal techniques, stated Officer Burns.137 This often means
reducing or eliminating unnecessary visual and aural stimuli, such as warning lights
and sirens. Also, officers are instructed to “get as much back up as you can to
approach this person safely,” stated Officer Myers states in the training video. 138 A
goal is “adequate [police presence] to handle the incident,” also stated Sergeant
Farris.139 However, if the individual “is endangering others you are going to have to
140
go in,” pointed out Officer Myers.



Gain Rapid Control. At some point, law enforcement officers will “need rapid and
overwhelming tactics to gain control,” stated Sergeant Farris. 141 “The idea is that we
want to use enough control tactics to bring this person under control as quickly as
possible. That way we can get the person restrained and delivered to medical
intervention,” stated Officer Myers. At the same time, “your goal is to restrain the
person with the minimum amount of fight. The more they fight, the greater the
142
chance for a negative outcome,” he said. A conducted energy device is a fast way
to restrain an individual with ExDS, pointed out Lenexa and Seattle police
officers.143 “While the TASER is cycling, have somebody restrain him and deliver
him to medics, if medics are present,” stated Officer Myers.144



Ensure Breathing. While the individual is restrained and until the individual is
transferred to medical care, law enforcement officers should not hinder the
subject’s ability to breathe. This may include placing them in a recovery position
and not subjecting their thorax to unnecessary weight. By definition, they will be
metabolically acidotic from the intense exertion that they have been demonstrating. This exertion will often continue while in handcuffs and the tendency may be
for officers to try to keep them pinned to the ground or against some type of solid
object until EMS arrives to take over. The problem with this is that the primary

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide entitled, “Intervention.” Also, slide entitled, “First Responder.”
137

138

Seattle Police Department, “Excited Delirium“ training video, 2007.

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide entitled, “The Goal.’
139

140

Seattle Police Department, “Excited Delirium“ training video, 2007.

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide 15.
141

142

Seattle Police Department, “Excited Delirium“ training video, 2007.

Seattle Police Department, “Excited Delirium” training video, 2007. Also, Sergeant Farris,
brief entitled, “Response to Excited Delirium Syndrome: Training Program for Police, Fire and
EMS. Lenexa, Johnson County, Kansas, undated, slide 15.
143

144

Seattle Police Department, “Excited Delirium“ training video, 2007.

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method for a subject in this situation to buffer the build-up of metabolic acid is to
be able to breathe at a faster rate and deeper volume than usual. Anything that
might restrict this could potentially make this condition worse and if the acidotic
condition reaches a certain threshold, the subject will have a cardiopulmonary
arrest.145 “Assign someone to watch and monitor subject’s face,” stated Officer
Burns. This is intended to detect if the individual is becoming unconscious. “Be
prepared to initiate resuscitation efforts,” stated Sergeant Farris, which includes
airway management, cardiopulmonary resuscitation (CPR), and/or automated
146
external defibrillator (AED). “…Take the handcuffs off the subject prior to CPR,”
147
stated Officer Burns. If officers are gasping for air after a struggle and the subject
is breathing calmly and easily, this may indicate that a subject is in jeopardy.
The Seattle and Lenexa protocols consider adequate back-up for police, rapidly
controlling the subject, and transitioning the subject to emergency medical care. These
practices are in keeping with the findings of the 2009 White Paper Report on Excited
Delirium Syndrome:
In subjects who do not respond to verbal calming and de-escalation techniques, control
measures are a prerequisite for medical assessment and intervention. When necessary,
this should be accomplished as rapidly and safely as possible. Recent research indicates
that physical struggle is a much greater contributor to catecholamine surge and
metabolic acidosis than other causes of exertion or noxious stimuli. Since these
parameters are thought to contribute to poor outcomes in ExDS, the specific physical
control methods employed should optimally minimize the time spent struggling, while
safely achieving physical control. The use of multiple personnel with training in safe
physical control measures is encouraged.148

Additionally, protocols should use sound practices based upon lessons that have been
learned, including consideration for the use of appropriate less-lethal devices that do
not exacerbate the situation, the subject’s ability to breathe, subject monitoring for consciousness, and preparation for resuscitation. The consensus of the panel is that the
control step outlined above (and its considerations) is a critical element of the protocol
and is reasonable and often necessary in order to provide the subject with the greatest
chance of survival.
Sedate

The consensus of
the panel is that the
control step … is a
critical element of
the protocol and is
reasonable and
often necessary in
order to provide
the subject with the
greatest chance of
survival.

All of the protocols require that emergency medical personnel respond to the scene
quickly to determine if the individual is in medical crisis, and if so, accept transfer from
police. Also, these protocols often (not universally) allow emergency medical personnel
to sedate if they determine an individual likely has ExDS. This will most often require law
enforcement assistance in maintaining control. “In order for [medics] to sedate [the
subjects], [police] are going to have to restrain [subjects]. [The medics] are going to
need a limb, holding it still long enough to inject a sedative,” stated Officer Myers.149, 150
145

Dr. Jeffrey D. Ho, comments on draft report provided on 11/27/2011.

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide 15.
146

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide entitled, “Lessons Learned.”
147

148

ACEP Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome.

149

Seattle Police Department, “Excited Delirium” training video, 2007
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In Lenexa, Kansas, emergency medical personnel may administer a 10mg intranasal
dose of midazolam [trade name Versed ]. If the individual is still combative after ten
minutes, medics may repeat the same dose. If the individual expels the intranasal dose
or attempts to bite, medics may administer an intramuscular injection 5mg dose of
midazolam. If medics can do an intravenous injection and the individual is combative,
they may administer a 2-5 mg dose of midazolam, repeating every five minutes until
151
adequate sedation is achieved.
The Minneapolis protocols, which the ACEP Task
Force examined and supported, advocate for use of IM Ketamine as the ideal sedative,
which has fewer complications than Versed (a respiratory depressant). They have over
152
10 years of experience with this in their system.
Sedation by emergency medical personnel, as soon after police control as possible, is
consistent with the findings of the 2009 White Paper Report on Excited Delirium
Syndrome, which stated:
After adequate physical control is achieved, medical assessment and treatment should
be immediately initiated…Most authorities, including this Task Force, posit the
153
beneficial use of aggressive chemical sedation as first-line intervention.

The White Paper views sedation as treating agitation associated with ExDS. It does not
prescribe a specific medication, but rather offers several, which are found in Annex A of
this report. In addition, the White Paper also shows medications being used by those
communities treating ExDS, the majority using midazolam. The White Paper also states
the following with regards to sedative doses:
[Recommended] doses are based upon consensus opinion. The actual effective dose of
all suggested medications is unknown due to a paucity of research. Because these
agents have respiratory and cardiovascular effects, continuous monitoring of both
should be performed as soon as feasible whenever parenteral sedation is administered.
When appropriate safety systems are in place, one should be aware of manufacturers
suggested dosing recommendations for other uses, but be prepared to use clinically
154
effective doses for the management of this condition.

This panel concurs with the findings of the Task Force regarding sedation.

[Editor’s note: Intranasal administration and other alternative methods of administration
are becoming available. Intranasal action is often slower and thus may have other challenges
operationally.]
150

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide entitled, “Medical
Protocol.”
151

152

Dr. Jeffrey D. Ho, comments on draft report provided on 11/27/2011.

153

ACEP Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p 14.

ACEP Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p 17.
The following communities use Midazolam: Miami, FL; Nashville, TN; Columbus, OH; and
Clark County (Las Vegas) NV. Minneapolis, MN uses Ketamine. Rochester, MN uses
Lorazepam.
154

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Transport
Transporting the subject to a medical facility is accomplished by emergency medical
personnel as soon as possible, so that the individual receives a follow-up medical
155
evaluation and any necessary treatment.
The Seattle and Lenexa protocols appropriately call for transport of ExDS cases to a
medical facility for follow-up evaluation and treatment. However, briefings did not
detail emergency department preparations and practices for such cases. As panel
member and nurse Theresa DiMaio stated, “Many emergency room nurses will not
156
know about excited delirium.” Therefore, knowledge of ExDS is needed for evaluation
and treatment at a medical facility, as well.
Upon arrival at a medical facility/emergency department, subjects presenting with
suspected ExDS should be managed as recommended by the White Paper and Dr. Vilke
et al. These include:
Acidosis. This is the buildup of acid in the body, possibly leading to coma or death. Law
enforcement and on-scene medics in the Seattle and Lenexa, Kansas, protocols
recognize acidosis as a component of ExDS. Notably, police follow the findings of the
White Paper: “Control measures that might interfere with ventilation should be
avoided.” Emergency room personnel should also be aware of acidosis as a component
of ExDS, as well as the White Paper’s recommended treatment:
“If [ExDS is] suspected based on the clinical situation or physical examination, fluid
resuscitation with intravenous fluids is prudent. In severe cases, sodium bicarbonate
may be used either empirically or based on laboratory results revealing significant
acidosis. Controversy exists regarding empiric use of sodium bicarbonate; the efficacy of
supplemental sodium bicarbonate is unknown, and has not been supported as routine
therapy for the metabolic acidosis of cardiac arrest.”157

The panel recognizes that this may be harmful if the subject/patient is hypokalemic,
although this will not likely be the case if profoundly acidotic.
Hyperthermia. This is a dangerously high body temperature. Treatment may be initiated
upon observation, though confirmation through “core temperature measurement is
preferred,” states the White Paper. It further recommends:
Basic cooling methods include removal of clothing and placement in a cool environment.
Active external cooling may be initiated, with misting of water on exposed skin,
providing air flow to enhance evaporative cooling, and placement of ice packs at the
neck, axillae, and groin. Rapid cooling by infusion of cold saline IV has been shown to be
effective in a number of other settings and can also be used. Care must be taken to
avoid treatment “overshoot” leading to hypothermia.
Once the patient is stabilized in the ED (emergency department) or hospital setting,
additional measures may be considered. In refractory or severe cases, immersion in cool
water can rapidly reduce core body temperature, though this may present some
difficulty with monitoring and treatment. A variety of external and internal temperature
control devices are now available and may also be considered. If NMS [neuroleptic

155

Seattle Police Department, “Excited Delirium“ training video, 2007.

156

Ms Theresa G. DiMaio, recorded panel proceedings, 12 April 2011.

157

Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p. 16.
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malignant syndrome] or malignant hyperthermia is suspected, dantrolene may be
indicated.158

Rhabdomyolysis. This is the breakdown of muscle fibers resulting in the release of
muscle fiber contents (myoglobin) into the bloodstream. This may be harmful to the
kidney and may result in kidney damage. Consequently, the White Paper recommends,
that rhabdomyolysis be “initially managed by fluid administration and urine
alkalinization with sodium bicarbonate.”159
Document
Documentation of ExDS cases should be done by emergency medical personnel and law
enforcement and embedded in their existing reporting systems. Lenexa has “stressed
the importance of extensive documentation of the incident to include photos, video,
160
and audio as well as detailed reports and supervisor response.” In Seattle, emergency
medical personnel conduct audio recordings of the proceedings. These “paint a fuller
161
picture” of the event as Officer Burns pointed out. Seattle police also complete a
162
computer-based ExDS report.
They “include as many of the ExDS factors … as
possible,” Officer Myers instructs. “The key one that is going to help us in determining
what kind of medical crisis this person was suffering from is going to be body
temperature. The body temperature is one of the key indicators that seems to
differentiate ExDS from other drug-related medical crises,” as Officer Myers also stated.
163
This documentation has several uses, to include:


Improving our understanding of the syndrome and improving responses;



Serving as training and evaluation tools;164



Evidence that can assist in follow-on investigations; 165



Litigation management;166 and



Identifying individuals with ExDS histories.

167

158

Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p. 16.

159

Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p. 16.

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide 25.
160

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide entitled, “Medical Monitoring.”
161

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slides 21-3, entitled “Computer Assistance.”
162

163

Seattle Police Department, “Excited Delirium“ training video, 2007.

Rick Wyant and Tom Burns, brief entitled “Excited Delirium: The First Response,” undated,
slide entitled, “Medical Monitoring.”
164

165

Seattle Police Department, “Excited Delirium“ training video, 2007.

Sergeant Farris, brief entitled, “Response to Excited Delirium Syndrome: Training Program
for Police, Fire and EMS. Lenexa, Johnson County, Kansas, undated, slide 16.
166

Chris Myers, Tom Burns, Review of appropriate information to be gained from EMS
(litigation control) to include statements made by subject, core body temperature records,
vital signs, and medications.
167

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Forensic Pathology
Despite the best efforts of first responders, it is likely that there will continue to be
deaths resulting from ExDS. “Some patients who develop ExDS and go into cardiac arrest
will not be resuscitated,” stated Dr. Vilke et al., and that has been observed by
emergency physicians “even when the cardiopulmonary arrest occurs in the setting of a
well-staffed and well-equipped hospital emergency department (ED).” “In the absence
of clearly stated case definitions and prospective clinical studies, treatment of ExDS
remains largely speculative,” stated Dr. Vilke et al.168
As early as 1996, considerations regarding the determination of the cause and manner
of death in ExDS were identified by Dr. Deborah Mash and others in the American
Journal of Emergency Medicine.169 Similarly, they were addressed in 2006 by Theresa
170
DiMaio in Excited Delirium Syndrome: Cause of Death and Prevention. This text
discusses the investigation, autopsy, and toxicology as well as the certification of death.
Moreover, these issues, as well as care recommendations for treatment, diagnosis, and
loss limitation can be found in several editions of Karch's Pathology of Drug Abuse.171
Takeuchi et al., found that in all these cases, it appeared that victims died of either
respiratory arrest or fatal cardiac dysrrhythmia. Diagnoses were supported by
postmortem exams showing pulmonary and cerebral edema with non-lethal selfinflicted injuries. The few who live long enough to be hospitalized often succumb to
disseminated intravascular coagulation, rhabdomyolysis and renal failure. These fatal
cardiopulmonary changes are thought to be the result of increased catecholamine stress
on the heart, myocardial hypertrophy, micro-angiopathy and fatal arrhythmias. The
proposed cause of these changes is debated.172, 173

As early as 1996, considerations regarding the
determination of the
cause and manner of
death in ExDS were
identified by Dr. Deborah
Mash and others in the
As the National Association of Medical Examiners (NAME) now recognizes ExDS, the American Journal of
path to broader acceptance and standardized procedures and training in this community Emergency Medicine.
has begun.
While the White Paper very generally addresses documentation of ExDS cases, it does
not address it in the same detail as the Seattle and Lenexa protocols. The consensus of
this panel is that the detailed documentation practices included in these protocols serve
as models for other communities. They are vital to better understanding the syndrome
and improving the collective responses.

Gary M. Vilke, et. al., “Excited Delirium Syndrome (EXDS): Defining Based on A Review of
the Literature,” The Journal of Emergency Medicine, February 2011, p. 6.
168

Theresa G. DiMaio (Author) and Vincent J.M. DiMaio M.D., “Excited Delirium Syndrome:
Cause of Death and Prevention,” CRC Press, 2006, Boca Raton, FL. Pp 75-81.
170

Steven B. Karch and Olaf Drummer, Karch's Pathology of Drug Abuse, Fourth Edition, CRC
Press, Taylor & Francis Group, Boca Raton, FL, December 15, 2008.
171

172

Charles V. Wetli, Deborah Mash, Steven B. Karch, Cocaine-associated agitated delirium and
the neuroleptic malignant syndrome, American Journal of Emergency Medicine, Volume 14,
Issue 4 , Pages 425-428, July 1996.
Asia Takeuchi, MD, Terence L. Ahern, BA, Sean O. Henderson, MD, “Excited Delirium,”
Western Journal of Emergency Medicine, Volume XII, no. 1, February 2011, pp 77-83.
173

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Conclusion
The implemented protocols appear to have prevented fatalities and the panel consensus is that this will likely continue. Whether use of these protocols will reduce lawsuits
is uncertain, but they will likely help agencies defend against them, especially if they
adhere to a policy of copious documentation – both at the scene and at autopsy.
However, there are still questions that remain that can be addressed through broader
acceptance of the syndrome, systematic documentation by first responders, and
continued research. Additionally, endorsement by the National Institute of Justice is
important in generating wider acceptance in the first responder communities and the
general public.

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Section 3:
Excited Delirium – What Work Remains?
This section reflects panel discussions that addressed the work that remains –
particularly with regard to research. The panel provided recommendations to improve
the understanding of ExDS and lead to a common treatment. These recommenddations encompass terminology, research, education, and stakeholder endorsement.

Terminology
Excited Delirium Syndrome
The panel agreed upon “An altered mental state with impaired cognition and perception, and severe psycho-motor agitation” as an acceptable definition for ExDS.174 There
was some debate regarding whether or not changing the “excited delirium” name might
garner broader support in the medical community while addressing the existing public
perceptions. A similar debate occurred in the Task Force that produced the White Paper
Report on Excited Delirium Syndrome .175 However, this panel, like the Task Force,
concluded that the name “excited delirium syndrome” has gained acceptance in law
enforcement and some aspects of the medical community. Moreover, a new name
would be a step backwards in terms of recognition, pointed out Sergeant Fred Farris.176
ExDS Steps and Indicators
The panel arrived at a general consensus for the basic steps for first responders in
dealing with ExDS cases (Identify, Control, Sedate, and Transport – and documentation).
The indicators below are based on findings in the medical literature and have been
reproduced on the quick reference card agreed upon by the panel. They should be
uniformly used by those communities addressing ExDS. As mentioned, these may not
present themselves uniformly, due to varied underlying medical conditions that may
generate ExDS. As panel member and medical researcher, Dr. Chris Hall stated, “the
more signs and symptoms, the higher the risk” of ExDS and its consequences. Some
signs and symptoms are more significant, and more common, than others. As previously
mentioned, the panel arrived at a general consensus for a quick-reference card for first
responders that includes a revised list of indicators.

Research
The goal of these research recommendations is to advance our understanding of ExDS in
order to improve the capability of first responders and provide better response and
treatment than perhaps exists today. Tangentially, it may also help guide the use of
control measures, first responder tactics, and even “the development [and
improvement] of less lethal/non-lethal weapons,” as panel member Dr. Mary Williams
177
pointed out.
In addition to the efforts described below, the panel recommends the
establishment of a responsible coordinating agent within the federal government.
This definition was provided primarily by Dr. Chris Hall, with input from panel members.
Recorded panel proceedings, 13 April 2011.
174

175

ACEP Excited Delirium Task Force, White Paper Report on Excited Delirium Syndrome, p. 4.

176

Sergeant Fred Farris, recorded panel proceedings, 12 April 2011.

177

Dr Mary Williams, recorded panel proceedings, 13 April 2011.
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Specifically, the NIJ could assign an office or program manager that would be
responsible to coordinate research efforts across the federal government (other
The panel recomstakeholders such as HHS, DHS, and DoD-AMEDD).178 Maintaining focus on the
mends the establish- objectives of this research will require dedicated stewardship. Such an agent must
ment of a responsible ensure coordinated efforts, continuously identify and address gaps in research, and be
an effective advocate for funding critical efforts by multiple agencies. The agent must
coordinating agent
guide the research to a workable solution.

within the federal
government.

Conduct an Epidemiological Study
How a problem is addressed is influenced by how it is defined. Excited delirium
syndrome has not yet been adequately defined. More specifically, it lacks a case
definition, describing what is unusual about the disease/syndrome in terms of the
population segment affected, timelines, etc. Such definition is needed to focus efforts
“leading to any further mitigation of this phenomenon.” The value of such a study was
179
pointed out by Dr Hall: “It will give us a case definition.” Some related epidemiology
180
studies have been conducted.
She further pointed out that such an epidemiological
study is being conducted in Canada, involving several cities, and that a similar study
should be conducted in the US.181 In addition to better defining those at risk, such an
epidemiological study may provide a statistical presentation of indicators, insights into
why some die and others survive, morbidity and mortality, and improvement to interventions.182 A case definition would ultimately guide research and future treatment.
Investigate Excited Delirium Fatalities in Psychiatric Patients
There is a tendency for researchers to focus on drug-related ExDS cases, because there
are seemingly more of these cases, relative to those in the psychiatric population.
However, “Some of the answers in research,” stated Theresa DiMaio, “lie with
psychiatric patients. That’s where it (ExDS) originates.” She also pointed out that they
are a “much cleaner case, because they are not on cocaine or methamphetamine and
183
yet they have the same presentation and manic behavior.”
Information on ExDS
fatalities in psychiatric patients may be available from medical examiners, as they are
required to investigate such sudden deaths.184
Collect and Assess Data on Excited Delirium Cases
Fatalities. This effort may provide insights into causes of death and biomarkers of this
syndrome. Data could come from accredited medical examiners, who are required to
keep blood samples after post-mortem exams, as well as their reports. Data should be
HHS is the US Department of Health and Human Services, DHS is the US Department of
Homeland Security, and DoD-AMEDD is the US Dept of Defense Army Medical Department.
178

179

Dr Chris Hall, recorded panel proceedings, 13 April 2011.

A. James Ruttenber, Janet Lawler-Heavner, Ming Yin, Charles V. Wetli, W. Lee Hearn, and
Deborah C. Mash, “Fatal Excited Delirium Following Cocaine Use: Epidemiologic Findings
Provide New Evidence for Mechanisms of Cocaine Toxicity,” Journal of Forensic Science,
1997;42(1):25-31.
180

181

Dr Chris Hall, recorded panel proceedings, 13 April 2011.

182

The benefits of epidemiology were summarized from several panel members’ comments.

183

Ms Theresa DiMaio, recorded panel proceedings, 12 April 2011.

184

Dr Vincent DiMaio, recorded panel proceedings, 13 April 2011.

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collected only on those clearly determined to be ExDS cases. In addition to ExDS
fatalities in psychiatric patients, this effort is likely to focus on cocaine-related ExDS
fatalities. “The largest group is chronic cocaine users,” stated panel member and cardiac
researcher, Dr. Steven Karch who, in a recent study of the neurochemical changes in 100
decedents, found that 96 were cocaine users and four were methamphetamine abusers.
185
None were known to have had previous psychiatric hospitalization.
Survivors. “You are only going to learn so much from the dead,” stated Dr. DiMaio. 186
This effort should seek interviews and blood samples from consenting ExDS survivors.
187
“There may be something different about those who survive ExDS,” stated Dr Hall.
Compare Assessments. This was proposed by panel member and medical researcher, Dr.
Kent Vrana. “One approach would be to identify and characterize those individuals who
display cardinal signs and symptoms of ExDS, but do not die. These characteristics could
then be compared with those of ExDS fatalities. The numbers are going to be much
188
smaller, but we can create a list of potential risk factors.”
This is a further argument
for genetic testing, in particular, a Genome Wide Association Study (GWAS) of the two
groups.
Investigate a Genetic Predisposition for Excited Delirium
“If we could just collect small amounts of tissues or blood,” stated Dr. Vrana, “then we
could ask the question is there an underlying polymorphism (genetic variation) or
polymorphisms that associate?” 189 “You have to deal with the genetic predisposition,”
stated Dr. DiMaio.190 Dr. Vrana proposed a possible investigative approach. Once
polymorphisms were identified from the blood/tissue samples, they could be genotyped
with statistical analysis following. “The [research] question is,” stated Dr. Vrana, “do you
find channelopathy polymorphisms in ExDS related deaths versus a suitably matched
population?” 191
Research the Pathophysiology of Excited Delirium
“We do not know the acute physiology of ExDS subjects. We need to get a better
understanding of their physiologic and metabolic state,” stated panel member and
medical researcher, Dr. William Bozeman.192 This understanding is key to treating ExDS
and possibly preventing deaths. In order to achieve this understanding, “What you want
to do is go down to the mechanisms,” stated Dr. DiMaio. 193 As Dr. Karch also added,
“You are talking about major molecular research.” 194

185

Dr Steven Karch, recorded panel proceedings, 13 April 2011.

186

Dr Vincent DiMaio, recorded panel proceedings, 13 April 2011.

187

Dr Chris Hall, recorded panel proceedings, 13 April 2011.

188

Dr. Kent Vrana, recorded panel proceedings, 13 April 2011.

189

Dr. Kent Vrana, recorded panel proceedings, 12 April 2011.

190

Dr Vincent DiMaio, recorded panel proceedings, 13 April 2011.

191

Dr. Kent Vrana, recorded panel proceedings, 13 April 2011.

192

Dr William Bozeman, recorded panel proceedings, 13 April 2011.

193

Dr Vincent DiMaio, recorded panel proceedings, 13 April 2011.

194

Dr Steven Karch, recorded panel proceedings, 13 April 2011.
Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Pursue a Model for Excited Delirium
One of the key research goals should be to pursue an acceptable model for ExDS. “I
195
don’t think we will get any answers until we get a chronic model,” stated Dr. Karch.
This may be problematic and will certainly be expensive. It is not that difficult to study
the long term affects of cocaine and methamphetamine in animals, but whether it will
prove possible to cause ExDS is not clear. What is clear is that both the heart and brain
One of the key re- must be studied, which eliminates the porcine model (the conduction system of their
search goals should hearts is too dissimilar from humans) though the rabbit model would reflect the cardiac
changes and be directly relevant to humans (same conduction system). Proteonomics
be to pursue an
and more routine pathology methods might provide very useful information.

acceptable model
for ExDS.

The preferred study for the changes that have already been proven to occur in human
brains would be best studied in a primate model, particularly one using the techniques
of functional magnetic resonance imaging (MRI). However, these studies are very
expensive and require specialized skills. In spite of the difficulties, this approach merits
serious consideration as it may well be that death in these cases is a function of some,
yet to be identified, mind-body connection.

Best Practices and Training
Efforts to further mitigate ExDS over the long term will require a concerted effort,
coordinated and guided by an appropriate federal agent. In the meantime, mitigating
this phenomenon will depend on using best known practices to treat it – which, while
somewhat speculative, appear to have achieved some success. This near-term
mitigation also depends on increasing awareness of ExDS and promulgating these best
known practices to treat it.
“Give us something we can use now,” stated Lenexa, Kansas Police Sergeant Fred Farris,
referring to first responders’ immediate needs to treat ExDS cases. “We need an end
product that we can work with while you are doing the research to find a way to stop
it.”196 Further amplifying this immediate need for treatment, panel member and Seattle
police officer Chris Myers stated, “translate it into something a federal judge can
understand.”197 The Panel, therefore, recommends the following for treating ExDS until
research can provide further information:
While ExDS is likely to be observed initially by police, “this is a clinical entity that can
enter the ED [emergency department] from any source (EMS [emergency medical
services], law enforcement, ED triage, etc),” states the 2009 White Paper. Thus, law
enforcement, paramedics, and hospital emergency departments should be capable of
identifying the syndrome recognizing that the identifiers will not present uniformly. In
order to move this effort forward, therefore, the panel recommends:
Survey Local Law Enforcement Organizations
A survey of local law enforcement jurisdictions should be completed through the
National Institute of Justice to determine community awareness of ExDS and its risks,
training and policies in dealing with it, and protocols to treat it. Selection of jurisdictions
should be inclusive of large and small departments, urban and rural settings, and small
195

Dr Steven Karch, recorded panel proceedings, 13 April 2011.

196

Sergeant Fred Farris, recorded panel proceedings, 13 April 2011.

197

Officer Chris Myers, panel proceedings, 13 April 2011.

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

jails as well as larger federal correctional institutions. Consideration should be given to
size, location, and population demographics.
Develop Educational Outreach Programs
The panel recommends that NIJ pursue an effort to gather and review best practices for
developing an ExDS response program that might serve as a framework for jurisdictions
across the country. These coordinated response programs will require policy guidelines,
techniques and procedures, planning considerations, training components (police,
paramedic, emergency room, dispatcher, administration), and community outreach.
The goal should be to make ExDS and its treatment known to all first responders and the
communities they serve. The components of these best practices should be general
enough that it allows communities to adapt them to local needs.

Stakeholder Endorsement
The panel recommends that the National Institute of Justice endorse and electronically
post this Panel’s Report along with the 2009 White Paper. This endorsement will help
gain acceptance of ExDS and its treatment throughout the criminal justice community.
Consistent with the panel recommendation to establish a responsible coordinating
agent at the Federal Level, that agent (and this panel) should seek support from national
research organizations. “If we are going to get molecular answers we are going to have
to go through national institutes,” stated Dr. Karch.198 Additionally, other stakeholder
groups should be included to ensure transparency and maintain open lines of
communication. Moreover, taking research to a solution for ExDS will require
considerable funding – which will likely entail a cooperative resourcing effort among
federal stakeholders. The panel, therefore, recommended pursuing support from the
following national research and other stakeholder organizations:

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


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






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198

American College of Emergency Physicians (ACEP);
American Medical Association (AMA);
American Psychiatric Association;
American Psychological Association (APA);
Center for Disease Control and Prevention (CDC);
Center for Orphan Drug Research;
National Alliance on Mental Illness (NAMI);
National Association of EMS Physicians (NAEMSP);
National Association of Medical Examiners (NAME);
National Institute of Drug Abuse (NIDA);
National Institutes of Health, possibly its Office of Rare Diseases Research;
International Association of Chiefs of Police (IACP);
National Sheriffs Association (NSA);
National Tactical Officers Association (NTOA);
US Department of Defense Joint Non-Lethal Weapons Program (JNLWP).
American Civil Liberties Union (ALCU);
Amnesty International (AI);
International Committee of the Red Cross (ICRC);

Dr Steven Karch, recorded panel proceedings, 13 April 2011.
Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Appendix
Sedation Agents for ExDS–type symptoms
Taken from Table 5 in 2009 White Paper Report on Excited Delirium Syndrome
by the American College of Emergency Physicians’ Excited Delirium Task Force

IN: Intranasal; IM: Intramuscular; IV: Intravenous
* Typical adult dosing for severe agitation.
† The Food and Drug Administration has issued “Black Box” warnings regarding potential serious
adverse effects (QT prolongation and torsades de points) with these agents. Clinicians should use
their clinical judgment regarding the risk / benefit ratio on a case by case basis.
†† Though widely used in clinical practice, haloperidol is not FDA approved for intravenous
administration.
Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

Special Panel Review of Excited Delirium
Less-Lethal Devices Technology Working Group
NIJ Weapons and Protective Systems Technologies Center

Institute for Non-Lethal Defense Technologies
Applied Research Laboratory
The Pennsylvania State University

The Habeas Citebook Ineffective Counsel Side