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Excited Delirium and In-custody Deaths. Richard Barney, MD FACEP Assistant Clinical Professor of Medicine UW Medflight EMS Medical Director- Rock County Beloit Memorial Hospital. In-Custody Deaths…. Why do some people die following a violent confrontation with police?

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excited delirium and in custody deaths

Excited Delirium and In-custody Deaths

Richard Barney, MD FACEP

Assistant Clinical Professor of Medicine

UW Medflight

EMS Medical Director- Rock County

Beloit Memorial Hospital

in custody deaths
In-Custody Deaths…
  • Why do some people die following a violent confrontation with police?
  • What role does the taser play, if any?
  • What role does position of the patient play
  • What can police officers do to prevent in-custody deaths?
  • What is EMS Role?
  • What is the ER Role?
typical scenario
Typical Scenario
  • Male subject creating a disturbance
  • Triggers 911 call
  • Obvious to police that subject will resist
  • Struggle ensues with multiple officers
    • May involve OC, Taser, choke holds, batons, etc.
typical scenario1
Typical Scenario
  • Physical restraints applied
    • Subject subdued in a prone position
    • Officers kneeling on subjects back
    • Handcuffs, ankle cuffs
    • Hogtying, hobble restraint
  • Prone vs. lateral positioning
  • Transported in a squad car to jail
typical scenario2
Typical Scenario
  • Continued struggle against restraints
    • Sometimes damages squad car
  • Apparent resolution period
    • Subject becomes calm or slips into unconsciousness
    • Labored or shallow breathing
    • Followed unexpectedly by…
typical scenario3
Typical Scenario
  • Death
    • Resuscitation efforts are futile
    • Los Angeles County EMS Study
      • 18 ED deaths witnessed by paramedics (all were restrained)
      • In 13 – rhythm documented
      • VT and asystole were most common
        • No ventricular fibrillation
      • All failed resuscitation

Source: Am J Emerg Med; 2001:19(3), 187-191

typical scenario4
Typical Scenario
  • The press:
    • Subject “died after being shocked with taser”
    • Implies cause and effect
  • The Fallacy: “Post hoc ergo proptor hoc”
typical aftermath
Typical Aftermath
  • Several weeks later – autopsy results…
    • Cause of Death
      • Excited delirium
      • Illicit stimulant drug abuse
      • Concurrent medical problems
      • Minimal injury from police confrontation
    • It wasn’t the taser after all
    • Officers exonerated
restraints and in custody deaths
Restraints and In-Custody Deaths
  • What roles do physical restraint, restraining technique and restraint position play in excited delirium deaths?
physical restraints
Physical Restraints

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

physical restraint issues
Physical Restraint Issues
  • Positional Asphyxia
    • Deaths have occurred with subjects restrained in a prone position
    • Theory: restricts breathing
    • The role of the position is unclear
    • Little data to support causality
    • Other factors are the likely culprits
physical restraint issues1
Physical Restraint Issues
  • No clinically significant changes in pulmonary function tests in healthy volunteers
    • Am J Forensic Med Pathol. 1998 Sep;19(3):201-5.
physical restraint issues2
Physical Restraint Issues
  • Restraint Asphyxia
    • Increased deaths in restrained patients
    • Rat Study
      • 3 fold increase in cocaine-related deaths among “restrained” rats
      • Life Sci. 1994;55(19):PL379-82.
    • Numerous studies now show restraint position not causative of death
    • Routinely now rejected in the courts
    • It isn’t the restraint that kills them, it is the Excited Delirium.
thomas a swift s electric rifle taser
Thomas A. Swift’s Electric Rifle (TASER)

Source: http://www.pointshooting.com/m26black.jpg

Source: http://www.keme.co.uk/~mack/M26.jpg

M26 Taser. Manufactured by Taser International

tasers use electricity
Tasers Use Electricity
  • It’s not the voltage it’s the amperage that is dangerous
  • Tasers use high voltage, but very low amperage
    • M26: 3.6 milliamps (average current)
    • M26:1.76 joules per pulse
    • X26: 2.1 milliamps (average current)
    • X26: 0.36 joules per pulse
  • X26 Taser delivers 19 pulses per second
taser effects
Taser Effects
  • High voltage affects nerves
  • Leads to intense muscle contraction
  • Does not affect muscles directly
taser safety

Taser Safety

215,000 officer have received taser “ride” in training

Over 500,000 reported taser deployments to date

No causal effects for death found

academic emer med 2006 june 13 6 589 95
Academic Emer. Med. 2006June;13(6):589-95
  • After 5 second taser ride on numerous subjects:
    • No EKG changes
    • No cardiac cell injury
    • No hyperkalemia
    • No acidosis
slide20

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

several forensic pathology studies have cited excited delirium not tasers as the cause of death

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

what is excited delirium
What is Excited Delirium?
  • An imminently life threatening medical emergency…
  • Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain.
  • Severe delirium and agitation
  • Not a crime in progress!
the freight train to death
The “Freight Train to Death”
  • How police restrain or position the subject will not stop “the freight train to death”
  • The sooner the severe agitation is terminated, the better
  • This requires EMS response and transport to the hospital.
what is excited delirium1
What is Excited Delirium?
  • Diagnostic criteria
    • Characteristic behavioral components
    • Metabolic Acidosis
    • Hyperthermia
    • Identifiable cause
      • Stimulant drugs
      • Psychiatric disease
      • Alcohol or medical problems rarely can cause
  • It does not explain all behavior that leads to confrontation with police
pathophysiology
Pathophysiology
  • Central nervous system effects:
    • Changes in dopamine transporter and receptors
    • High release of other neurotransmitters
    • Accounts for behavioral changes
    • Accounts for hyperthermia
behavioral components delirium
Behavioral Components: Delirium
  • Delirium:
    • “Off the track”
    • Confusion
    • Clouding of consciousness
    • Shifting attention
    • Disorientation
    • Hallucinations
    • Onset rapid – acute
    • Duration brief – transient
behavioral components excited agitated
Behavioral Components:Excited (Agitated)
  • Extreme agitation, increased activity
    • Aggravated by efforts to subdue and restrain
    • Not likely to comply after one or two tasers
    • Pressured speech, grunting
    • Inappropriate words and flight of ideas.
behavioral components excited agitated1
Behavioral Components:Excited (Agitated)
  • Violent or aggressive behavior
    • Towards inanimate objects, especially smashing glass
    • Towards self, others or police
  • Noncompliant with requests to desist
  • Superhuman strength
  • Insensitive to pain
excited delirium
Excited Delirium
  • Hyperthermia
    • High body temperature
    • 105 – 113 oF
    • Drug’s effect on temperature control center in brain (hypothalamus)
    • Tell-tale signs:
      • Profuse sweating
      • Undressing – partial or complete
excited delirium1
Excited Delirium
  • Hyperthermia
    • Aggravated by
      • increased activity
      • the ensuing struggle
      • warm humid weather (summertime)
      • dehydration
      • certain therapeutic medications
excited delirium2
Excited Delirium
  • Metabolic Acidosis
    • Potentially life threatening
      • Elevated blood potassium level
    • Factors: dehydration, increased activity
  • Survivors:
    • Kidney damage due to muscle breakdown
    • May require dialysis
excited delirium the usual suspects
Excited Delirium: The Usual Suspects
  • #1 Cause: Stimulant Drug Abuse
    • Acute intoxication
    • Superimposed on chronic abuse
    • Acute intoxication triggers the event
excited delirium the usual suspects1
Excited Delirium: The Usual Suspects
  • Underlying psychiatric disease
    • First described in 1849 before cocaine was first extracted from cocoa leaf
    • Mania (Bipolar Disorder)
    • Psychosis (Schizophrenia)
  • Noncompliance with medications to control psychosis or bipolar disorder
    • Unusual – #2 Cause
  • Rare: New onset schizophrenia
stimulant drugs
Stimulant Drugs
  • Cocaine
    • The major offender
    • On the rise due to “crack epidemic”
  • Toxicology studies show…
    • Low to moderate levels of cocaine
    • High levels of benzoylecognine (the major breakdown product of cocaine)
    • Suggests recent use superimposed on chronic abuse
stimulant drugs1
Stimulant Drugs
  • Other known culprits include:
    • Methamphetamine
    • Phencyclidine (PCP)
    • LSD
  • Cocaethylene = Cocaine + Alcohol
    • Toxic to the heart
    • Unknown role in excited delirium deaths
concurrent health conditions
Concurrent Health Conditions
  • Obesity
  • Heart Disease
    • Coronary artery disease
    • Cardiomegaly
    • Hypertrophic cardiomyopathy
    • Myocarditis
    • Fibrotic heart
autopsy proof
Autopsy Proof
  • Specialized laboratories can identify changes in brain chemistry that are characteristic of excited delirium
  • Blood and brain tissue levels of benzoylecognine and cocaine
    • Typical ratio 5:1
tasers and excited delirium deaths
Tasers and Excited Delirium Deaths
  • It’s not the Taser
  • Many in-custody deaths long before tasers were ever used
    • Documented in 1980s medical literature
  • Deaths of persons not in custody
    • Found naked in bathrooms
    • Wet towels
    • Empty ice cube trays scattered about
    • A futile effort to cool themselves
slide41

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

recognizing excited delirium
Recognizing Excited Delirium
  • Agitation or Excitement = Increased activity and intensity
    • Aggressive, threatening or combative – gets worse when challenged or injured
    • Amazing feats of strength
    • Pressured loud incoherent speech
    • Sweating (or loss of sweating late)
    • Dilated pupils/less reactive to light
    • Rapid breathing
recognizing excited delirium1
Recognizing Excited Delirium
  • Delirium = Confusion
    • Disoriented
      • Person, place, time, purpose
    • Rapid onset over a short period of recent time
      • “He just started acting strange”
    • Easily distracted/lack of focus
    • Decreased awareness and perception
    • Rapid changes in emotions (laughter, anger, sadness)
recognizing excited delirium2
Recognizing Excited Delirium
  • Psychotic = bizarre behavior
    • Thought content inappropriate for circumstances
    • Hallucinations (visual or auditory)
    • Delusions (grandeur, paranoia or reference)
    • Flight of ideas/tangential thinking
    • Makes you feel uncomfortable
bad behavior other reasons
Bad Behavior: Other Reasons
  • Alcohol intoxication or withdrawal
  • Other drug use problems
    • Example: Cocaine psychosis
  • Pure psychiatric disease
  • Head injury
  • Dementia (Alzheimer’s Disease)
  • Hypoglycemia
  • Hyperthyroidism
alternative strategy
Alternative Strategy
  • Attempt verbal de-escalation
  • Summon back-up quickly
  • Summon EMS as early as possible
  • Use taser before a struggle ensues
  • Jump the subject and administer tranquillizer
  • Back off and contain the subject without restraint
  • Once calm transport (no restraints?)
  • Minimize struggle and restraints
  • Unrealistically simplified?? – Maybe!
the ideal drug
The “Ideal” Drug
  • Rapid effective tranquilization
    • No repeat dosing
  • No significant adverse effects
    • respiratory depression
    • cardiovascular depression
    • neurological adverse effects
  • Easy to administer (IM)
  • Allows easy assessment of neurological status on ED arrival
in search of the ideal drug
In Search of The “Ideal” Drug
  • Benzodiazepines
  • Neuroleptics
  • Atypical antipsychotics
  • Ketamine
benzodiazepines
Benzodiazepines
  • Effective
  • But usually require repeat doses
  • Adverse reactions:
    • Hypotension
    • Respiratory Depression
    • Too long to take effect
    • Over sedation
neuroleptics and atypical antipsychotics
Neuroleptics and Atypical Antipsychotics
  • Rapid onset (10 – 15 minutes or less)
    • Do we have 15 minutes?? NO
  • Can be very effective in a single dose
  • Prolong the QT Interval (Droperidol)
  • Target dopamine D2 receptors
    • May exacerbate hyperthermia
    • HALDOL or GEODON
ketamine
Ketamine
  • Very rapid onset of action (<5 minutes)
  • Highly effective in a single dose
  • Favorable safety profile in healthy patients
  • Potential adverse effects:
    • Adrenergic over stimulation in excited delirium
    • “Emergence reactions” in adults
    • Dose 3-4 mg/Kg IM
rapid chemical sedation is life saving

Rapid Chemical Sedation is Life-saving

Get a chemical restraint drug into the patient at once.

Remove physical restraints when feasible

Never allow hobble or prone restraint!

immediate exam

Immediate Exam

Core temperature

Blood gas

CBC and electrolytes

Stat glucose

Toxicology

EKG

Urine for myoglobin

CPK

immediate treatment
Immediate Treatment
  • Dehydration/Metabolic Acidosis:
    • IV NS X 2 W/O Get ABG Bicarb for under 7.0
  • Hyperthermia:
    • Cool environment, disrobe, tepid mist and fanning, cooling blankets
  • Hyperkalemia?:
    • Fluids, Calcium Chloride, Sodium Bicarbonate, Albuterol
psychiatric history
Psychiatric History
  • Diagnosis
  • On Meds?
  • Has patient stopped meds?
  • Schizophrenia
  • Personality disorder
  • Manic disorder
summary
Summary
  • Excited Delirium is an imminently life threatening medical emergency, not a crime in progress
  • In-custody deaths likely related to excited delirium
  • Tasers – if used early – may help (remains unproven)
  • ALS medics can give potent tranquilizers
  • Rapid aggressive medical stabilization needed
summary1
Summary
  • Beware of potential side effects of therapeutic drugs
  • Treat for hyperthermia, dehydration, metabolic acidosis and potential hyperkalemia