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Excited Delirium Syndrome (ExDS): Defining Based on a Review of the Literature

      Abstract

      Background

      Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, “superhuman” strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as “Excited Delirium” deaths.

      Objectives

      This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations.

      Discussion

      Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both.

      Conclusions

      Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.

      Keywords

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      References

        • Bell L.
        On a form of disease resembling some advanced stages of mania and fever, but so contradistinguished from any ordinary observed or described combination of symptoms as to render it probable that it may be overlooked and hitherto unrecorded malady.
        Am J Insanity. 1849; 6: 97-127
        • Di Maio T.G.
        • Di Maio V.J.M.
        Excited delirium syndrome cause of death and prevention.
        1st edn. Taylor & Francis Group, Boca Raton, FL2006 (1–60)
        • Fishbain D.A.
        • Wetli C.V.
        Cocaine intoxication, delirium and death in a body packer.
        Ann Emerg Med. 1981; 10: 531-532
        • Wetli C.V.
        Fatal cocaine intoxication.
        Am J Forensic Med Pathol. 1987; 8: 1-2
        • Ruttenber A.J.
        • Lawler-Heavner J.
        • Yin M.
        • Wetli C.V.
        • Hearn W.L.
        • Mash D.C.
        Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity.
        J Forensic Sci. 1997; 42: 25-31
        • Stratton S.J.
        • Rogers C.
        • Brickett K.
        • Gruzinski G.
        Factors associated with sudden death of individuals requiring restraint for excited delirium.
        Am J Emerg Med. 2001; 19: 187-191
        • Ross D.L.
        Factors associated with excited delirium deaths in police custody.
        Mod Pathol. 1998; 11: 1127-1137
        • Grant J.R.
        • Southall P.E.
        • Mealey J.
        • Scott S.R.
        • Fowler D.R.
        Excited delirium deaths in custody past and present.
        Am J Forensic Med Pathol. 2009; 30: 1-5
        • Detweiler M.B.
        • Mehra A.
        • Rowell T.
        • Kim K.Y.
        • Bader G.
        Delirious mania and malignant catatonia: a report of 3 cases and review.
        Psychiatr Q. 2009; 80: 23-40
        • Karch S.B.
        Cardiac arrest in cocaine users.
        Am J Emerg Med. 1996; 14: 79-81
        • Wetli C.V.
        • Fishbain D.A.
        Cocaine-induced psychosis and sudden death in recreational cocaine users.
        J Forensic Sci. 1985; 30: 873-880
      1. Sullivan L. Death by excited delirium: diagnosis or coverup? National Public Radio, All Things Considered, February 26, 2007. Available at: http://www.npr.org/templates/story/story.php?storyId=7608386. Accessed July 1, 2009.

        • Buck C.J.
        The international classification of diseases, 9th revision.
        in: Mental disorders. Elsevier Health Sciences, Philadelphia2009: 290-319
        • Barnett J.H.
        • Werners U.
        • Secher S.M.
        • et al.
        Substance use in a population-based clinic sample of people with first-episode psychosis.
        Br J Psychiatry. 2007; 190: 515-520
        • Mash D.C.
        Biochemical brain markers in excited delirium deaths.
        in: Kroll M.W. Ho J.D. TASER conducted electrical weapons: physiology, pathology, and law. Springer, New York2009: 365-377
        • Karch S.B.
        Karch’s pathology of drug abuse.
        4th edn. Taylor & Francis Group CRC Press, Boca Raton, FL2009 (45–65)
        • Allam S.
        • Noble J.S.
        Cocaine-excited delirium and severe acidosis.
        Anesthesia. 2001; 56: 385-386
        • Bunai Y.
        • Akaza K.
        • Jiang W.X.
        • Nagai A.
        Fatal hyperthermia associated with excited delirium during an arrest.
        Leg Med (Tokyo). 2008; 10: 306-309
        • Escobedo L.G.
        • Ruttenber A.J.
        • Agocs M.M.
        • Anda R.F.
        • Wetli C.V.
        Emerging patterns of cocaine use and the epidemic of cocaine overdose deaths in Dade County, Florida.
        Arch Pathol Lab Med. 1991; 115: 900-905
        • Gruszecki A.C.
        • McGwin G.
        • Robinson A.
        • Davis G.G.
        Unexplained sudden death and the likelihood of drug abuse.
        J Forensic Sci. 2005; 50: 1-4
        • Ruttenber A.J.
        • McAnally H.B.
        • Wetli C.V.
        Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome.
        Am J Forensic Med Pathol. 1999; 20: 120-127
        • Ruttenber A.J.
        • Sweeney P.A.
        • Mendlein J.M.
        • Wetli C.V.
        Preliminary findings of an epidemiologic study of cocaine-related deaths, Dade County, Florida, 1978-85.
        NIDA Res Monogr. 1991; 110: 95-112
        • Stephens B.G.
        • Jentzen J.M.
        • Karch S.
        • Wetli C.V.
        • Mash D.C.
        National Association of Medical Examiners position paper on the certification of cocaine-related deaths.
        Am J Forensic Med Pathol. 2004; 25: 11-13
        • Ho J.D.
        • Heegaard W.G.
        • Dawes D.M.
        • et al.
        Unexpected arrest-related deaths in America: 12 months of open source surveillance.
        West J Emerg Med. 2009; 10: 68-73
        • Karch S.B.
        • Wetli C.V.
        Agitated delirium versus positional asphyxia.
        Ann Emerg Med. 1995; 26: 760-761
        • Karch S.B.
        • Stephens B.G.
        Drug abusers who die during arrest or in custody.
        J R Soc Med. 1999; 92: 110-113
        • Morrison A.
        • Sadler D.
        Death of a psychiatric patient during physical restraint.
        Med Sci Law. 2001; 41: 46-50
        • Hall C.
        • 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.
        Acad Emerg Med. 2009; 16: S198-S199
        • Mirchandani H.G.
        • Rorke L.B.
        • Sekula-Perlman A.
        • Hood I.C.
        Cocaine-induced agitated delirium, forceful struggle, and minor head injury: a further definition of sudden death during restraint.
        Am J Forensic Med Pathol. 1994; 15: 95-99
        • Mash D.C.
        • Duque L.
        • Pablo J.
        • et al.
        Brain biomarkers for identifying excited delirium as a cause of sudden death.
        Forensic Sci Int. 2009; 190: e13-e19
        • Mash D.C.
        • Pablo J.
        • Ouyang Q.
        • et al.
        Dopamine transport function is elevated in cocaine users.
        J Neurochem. 2002; 81: 292-300
        • Hick J.L.
        • Smith S.W.
        • Lynch M.T.
        Metabolic acidosis in restraint-associated cardiac arrest: a case series.
        Acad Emerg Med. 1999; 6: 239-243
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        4th edition, text revision. American Psychiatric Association, Washington, DC2000
      2. Ho J, Dawes D, Ryan F, et al. Catecholamines in simulated arrest scenarios. Australasian College of Emergency Medicine Winter Symposium; June 25, 2009.

        • Hick J.L.
        • Ho J.D.
        Ketamine chemical restraint to facilitate rescue of a combative "jumper".
        Prehosp Emerg Care. 2005; 9: 85-89
        • Roberts J.R.
        • Geeting G.K.
        Intramuscular ketamine for the rapid tranquilization of the uncontrollable, violent, and dangerous adult patient.
        J Trauma. 2001; 51: 1008-1010
        • Roberts J.R.
        Rapid tranquilization of violently agitated patients.
        Emerg Med News. 2007; 29: 15-18
        • Bouchama A.
        • Dehbi M.
        • Chaves-Carballo E.
        Cooling and hemodynamic management in heatstroke: practical recommendations.
        Crit Care. 2007; 11: R54