The syndrome of excited delirium

In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review

Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration. To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement. In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself. After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.

A retrospective cohort study of pre-hospital agitation management by advanced paramedic practitioners in critical care

Introduction: Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS) are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness of chemical sedation and any associated complications.Methods: A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used as the primary outcome measure.Results: A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical restraint.Conclusion: Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.

Restraint asphyxia. An analysis of the circumstances and mechanism of death in agitated, physically restrained individuals

W ostatnich latach media coraz częściej poruszane są przypadkami śmierci młodych zazwyczaj osób, w trakcie zatrzymywania przez policję. Śmierć w tych przypadkach dotyka zazwyczaj osoby pobudzone psychoruchowo, obezwładniane z użyciem siły, a badania pośmiertne nie wykazują jednoznacznej urazowej przyczyny zgonu. Celem pracy jest próba ustalenia mechanizmu i okoliczności zgonów w trakcie obezwładniania osób pobudzonych psychoruchowo. Analizie poddano przypadki opiniowane od 2010 roku, zarówno jako sekcje zwłok, jak i oceniane na podstawie materiału aktowego. W analizowanym okresie ZMS w Krakowie wydał opinie w 10 tego typu przypadkach, w dziewięciu na podstawie własnych sekcji zwłok, w jednym na podstawie materiału aktowego. We wszystkich nastąpiło nagłe zatrzymanie krążenia lub utrata przytomności, a resuscytacja okazywała się nieskuteczna. W sześciu przyczyną pobudzenia była ostra psychoza, w czterech działanie narkotyków, zazwyczaj w wysokim stężeniu. Tylko w pięciu przypadkach stwierdzono obecność wybroczyn w spojówkach. Najbardziej prawdopodobną przyczyną śmierci było współistnienie nasilonego wysiłku fizycznego spowodowanego patologicznym pobudzeniem psychoruchowym, z przymusowym unieruchomieniem pogarszającym funkcjonowanie układu oddechowego. Mechanizm ten jest określany jako asfiksja restrykcyjna. Restraint asphyxia. An analysis of the circumstances and mechanism of death in agitated, physically restrained individuals Recent years saw frequent media reports of young people who die while they are being arrested by the police. Death in these circumstances affects people who are agitated and restrained with the use of force, with their autopsies indicating no unequivocally traumatic cause of death. The goal of this study was to identify the mechanism and circumstances of sudden deaths in agitated individuals who are being restrained. Ten cases evaluated at our center since 2010 were included in this study: nine involved forensic postmortem examination and one involved casefile analysis. In each case there was sudden cardiac arrest or at least a loss of consciousness, and the cardiopulmonary resuscitation proved ineffective. In six cases the cause of agitation was acute psychosis, in four it was an effect of narcotics, usually in high concentration. Conjunctival petechiae were detected in only five cases. The most probable cause of death in the evaluated cases was the combination of physical exertion caused by pathological psychomotor agitation and forcible restraint, hindering the function of the respiratory system. This mechanism is known as restraint asphyxia.

Elektroschockdistanzwaffen Taser® X2 und T7

Die medizinische Beurteilung von Verletzungen und potenzieller todesursächlicher Relevanz einer Stromexposition durch eine Elektroschockdistanzwaffe beschränkt sich nicht allein auf die situativen Gegebenheiten und die morphologische Befunderhebung, sondern beinhaltet auch eine intensive Analyse polizeilicher Ermittlungen und die Auswertung von Zeugenaussagen sowie vorangegangener medizinischer Maßnahmen. Insbesondere bei zeitlich relevanter Nähe zwischen Exposition und Todeseintritt muss die Wirkung der übertragenen Stromimpulse in Zusammenhang mit der meist komplexen Einsatzsituation und der medizinischen Vorgeschichte des Geschädigten beurteilt werden. Ein detailliertes Wissen über die konkrete und auch abstrakte Wirkungsweise, Wirksamkeit und Risiken von Elektroschockdistanzwaffen ist hierfür unabdingbar.

Sudden Unexpected Death after a mild trauma: The complex forensic interpretation of cardiac and genetic findings

A 55-year-old man affected by a psychotic disorder suddenly died during a quarrel with his father. The autopsy excluded traumatic causes of death, and the cardiac examination identified a severe cardiomegaly with biventricular dilatation of very likely multifactorial origin. Toxicological and pharmacogenetic analyses excluded a fatal intoxication and identified the presence of the antipsychotic drug fluphenazine in the therapeutic range in a normal metabolizer. The screening for genetic variations highlighted a novel heterozygous single-nucleotide variant in the exon 36: c 0.4750C>A (p.Pro1584Thr) of the Ryanodine Receptor Type 2 (RYR2) gene. The mutation detected can be classified as Likely Pathogenic according to the American College of Medical Genetics and Genomics (ACMG) criteria. RYR2 variation has been associated to catecholaminergic polymorphic ventricular tachycardia (CPVT), a disease currently recognized as one of the most malignant cardiac channelopathies, expressed mostly in young patients, normally in the absence of structural heart disease. The victim late middle age, compared to juvenile onset of CPVT reported in literature, his clinical history, his structurally altered heart, circumstances at death and the absence of phenotype-related variations of dilated cardiomyopathy genes, suggested that the fatal arrhythmia could have been caused by an acquired form of dilated cardiopathy/cardiomyopathy. However, the contribution of the genetic variant to death cannot be completely ruled out, since the significance of a VUS or of a novel variant depends on the data available at the time of investigation, and should be periodically evaluated. We discuss the contribution of the structural alteration and of the variant detected, as well as the role of the molecular autopsy in forensic examination, which can make a significant contribution for inferring both cause and manner of death.

Patient Outcomes Following Ketamine Administration for Acute Agitation with a Decreased Dosing Protocol in the Prehospital Setting

BACKGROUND

Agitated behaviors are frequently encountered in the prehospital setting and require emergent treatment to prevent harm to patients and prehospital personnel. Chemical sedation with ketamine works faster than traditional pharmacologic agents, though it has a higher incidence of adverse events, including intubation. Outcomes following varying initial doses of prehospital intramuscular (IM) ketamine use have been incompletely described.

OBJECTIVE

To determine whether using a lower dose IM ketamine protocol for agitation is associated with more favorable outcomes.

METHODS

This study was a pre-/post-intervention retrospective chart review of prehospital care reports (PCRs). Adult patients who received chemical sedation in the form of IM ketamine for agitated behaviors were included. Patients were divided into two cohorts based on the standard IM ketamine dose of 4mg/kg and the lower IM dose of 3mg/kg with the option for an additional 1mg/kg if required. Primary outcomes included intubation and hospital admission. Secondary outcomes included emergency department (ED) length of stay, additional chemical or physical restraints, assaults on prehospital or ED employees, and documented adverse events.

RESULTS

The standard dose cohort consisted of 211 patients. The lower dose cohort consisted of 81 patients, 17 of whom received supplemental ketamine administration. Demographics did not significantly differ between the cohorts (mean age 35.14 versus 35.65 years; P = .484; and 67.8% versus 65.4% male; P = .89). Lower dose subjects were administered a lower ketamine dose (mean 3.24mg/kg) compared to the standard dose cohort (mean 3.51mg/kg). There was no statistically significant difference between the cohorts in intubation rate (14.2% versus 18.5%; P = .455), ED length of stay (14.31 versus 14.88 hours; P = .118), need for additional restraint and sedation (P = .787), or admission rate (26.1% versus 25.9%; P = .677). In the lower dose cohort, 41.2% (7/17) of patients who received supplemental ketamine doses were intubated, a higher rate than the patients in this cohort who did not receive supplemental ketamine (8/64, 12.5%; P <.01).

CONCLUSION

Access to effective, fast-acting chemical sedation is paramount for prehospital providers. No significant outcomes differences existed when a lower dose IM ketamine protocol was implemented for prehospital chemical sedation. Patients who received a second dose of ketamine had a significant increase in intubation rate. A lower dose protocol may be considered for an agitation protocol to limit the amount of medication administered to a population of high-risk patients.

Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."

Arrest-related death on the basis of a drug-induced excited delirium syndrome

AIMS

In typical arrest-related death (ARD) scenarios, the victims often show signs of excited delirium syndrome (ExDS), intoxication, exhaustion and/or suffered from a preexisting physical or psychiatrical condition, all of which could have caused or at least triggered the person's death. Since autopsy findings are very rare in such cases, a clear clinicopathologic diagnosis and thus mechanism of death is rarely found.

METHODS

We present a case of a 25-year old woman, who died while being arrested by the police. Based on the patient's medical history, autopsy findings, contradicting witness testimonies, and reliable clinical and toxicological blood parameters, the most probable diagnosis is discussed.

RESULTS

The cause of death was determined as cardiac arrest subsequent to a combination of excited delirium syndrome, physical exhaustion and respiratory impairment. The manner of death was unnatural and juridically, the charges were dropped.

CONCLUSIONS

In cases, where the cause and mechanism of death can only be diagnosed by exclusion, police collaboration, detailed clinical history (past and present) as well as clinical blood parameter analyses are necessary to help evaluating possible contributing factors and the most probable cause of death in ARD.

Deaths Associated With Community Donation Bins: A Ten-Year Retrospective Review Describing Five Cases in British Columbia and Ontario

Introduction

Community donation bins have become more common in the urban setting over the past several years. Many nonprofit organizations use these sturdy metal enclosures for unobserved collection of various donated items such as clothing, books, and household items. Although the donated items are often of low individual value, donation bins may become a target of individuals in low socioeconomic situations seeking desired items for personal use or resale, or for personal shelter within the bin.

Methods

To identify donation bin-associated deaths, we reviewed cases taken under the jurisdiction of the coroner for investigation in the provinces of British Columbia and Ontario, Canada, over the years 2009 to 2019.

Results

We present the circumstances and postmortem findings of five deaths that occurred in British Columbia and Ontario (Canada) between 2009 and 2019, wherein the decedents were each believed to have been reaching into donation bins and became caught within the door mechanism and died as a consequence of compression asphyxia involving the chest and/or neck.

Discussion

Donation bins have the potential for harm when individuals attempt to access the bin contents through the entry portal. We advocate for greater attention and changes in the placement location and/or design of these potentially dangerous devices.

Can acute stress be fatal? A systematic cross-disciplinary review

In this review it is discussed if acute stress can be fatal. The review is based on literature searches on PubMed, PsycINFO as well as Web of Science. Literature concerning the conditions excited delirium syndrome (ExDS), malignant catatonia, takotsubo cardiomyopathy (TCM), and capture myopathy (CM) is reviewed and compared. The aim of the article is to identify and discuss a possible fatalness as well as a common pathophysiology behind these conditions. This includes a deregulated autonomic nervous system, neurocardiac reasons for myocardial damage, and rhabdomyolysis. We conclude that these conditions could be different manifestations of the same pathophysiological phenomenon. In addition, we suggest that it is possible to die from acute stress, but that it requires a prior sensitization, as seen in cocaine abusers and certain psychiatric patients, to render individuals disposed to an extreme autonomic nerve reaction. Lay summary This article compares different conditions in humans and in other animals, where it appears as if the human or animal dies with no other reason than being submitted to an extreme condition of mental stress. The conditions examined via a literature search are excited delirium syndrome, malignant catatonia and takotsubo cardiomyopathy in humans, and a capture myopathy in different mammals. The article theoretically suggests that one can die solely from acute stress, but that different forms sensitization probably goes ahead of such a fatal stress reaction. E.g. in cocaine addicts, some psychiatric patients, and in wild animals formerly subjected to stress an extreme sympathetic stress response might be immediately fatal. The article also theorizes that excited delirium syndrome, malignant catatonia, and capture myopathy could be more severe and acute variants of the temporary condition seen in takotsubo patients, also known as patients with broken heart syndrome.

Manner of Death Certification After Significant Emotional Stress: An Inter-Rater Variability Study and Review of the Literature

Not commonly seen, the risk of sudden death after significant emotional stress has been reported since antiquity and incorporated into folk wisdom, reflected by phrases such as "scared to death" and "broken heart." A typical "victim" suffers from significant and often life-threatening natural diseases, making determination of the manner of death complicated, and at times controversial. The present study is designed to assess inter-rater variability and nonuniformity and controversy seen in manner of death certification in certain cases of death with significant stress involved in the circumstances of death. Members of the National Association of Medical Examiner (NAME) were surveyed to assess differences in manner of death certification for eight sudden unexpected death scenarios in middle-aged men and women with underlying cardiac disease after significant stressful events including: being chased down a lonely road followed by a verbal confrontation, a roll-over motor vehicle collision (MVC) without injuries, a fall from a wheelchair in a MVC, an alleged armed robbery, an involuntary commitment, an arrest by police, sexual intercourse, and a severe panic attack with breathing problems. In all cases, the autopsy examination revealed hypertensive and arteriosclerotic cardiovascular disease. In all cases, natural diseases were identified as significant contributing condtions, including emphysema in six cases and diabetes mellitus in three. Eighty-six responses were collected. The results show wide inter-rater variability, ranging from very good to poor (Kappa ranges from 0.16 to 0.94). One hundred fifty-five comments were collected. Most of the comments addressed more than one topic and were followed by discussions, open questions, and responders' experiences with previous cases and legal proceedings. Our data show that cases of sudden death after significant stress have almost complete agreement in four cases and very high inter-rater variability in the other four. We propose that a detailed analysis of each case and an algorithmic approach could improve the predictability of the outcomes of death investigations for the legal system and for families.

Electrical weapons and excited delirium: shocks, stress, and serum serotonin

It has been suggested that a CEW (conducted electrical weapon) exposure could elicit a stress response that could cause ExDS (excited delirium syndrome). There are some parallels between the signs of ExDS and serotonin syndrome (SS). Electroconvulsive therapy raises serotonin levels and therefore provides a plausible link between CEW applications and elevated serotonin levels. This study was designed to determine whether a CEW exposure elevates serum serotonin. A total of 31 police academy cadets were exposed to a very broad-spread 5-s CEW stimulus from a TASER brand X26 CEW. Blood was drawn before and after the exposure and at 24 h post exposure to measure serum serotonin levels. Lactic acid and cortisol levels were also compared. Median serum serotonin levels were 30 IQR (21,46), 36 IQR (22,50), and 32 IQR (21,45) ng/mL before exposure, after exposure, and 24 h after exposure (NS by pooled comparisons). The increase from baseline to post-test serotonin (∆ median = +6, ∆ mean = +2.7) ng/mL was not significant by a paired T-test (p = .29) but was significant by the Wilcoxon signed-rank test (p = .037). The increase to post-test log serotonin was not significant by a paired T-test (p = .13) but was significant by the Wilcoxon test (p = .049). All serotonin levels remained within the normal reference range of 0-200 ng/mL. Post-hoc analysis demonstrated that the study was powered to detect a ½ SD change, in log serotonin, with a 90% likelihood. With a very-broad electrode spread, CEW exposure did not significantly raise serum serotonin levels.

Eight years of psychiatric examination of detainees by forensic physicians in the Netherlands

BACKGROUND

Forensic physicians are responsible for first-line medical care of detainees (individuals held in custody) in the police station. The Dutch police law contains a 'duty of care', which gives the police responsibility for the apparent mentally ill and/or confused people they encounter during their work. The police can ask a forensic physician to do a primary psychiatric assessment of any apparent mentally ill detainee. The forensic physician determines if the apparent mentally ill behavior of the detainee is due to a somatic illness, or has a psychiatric cause for which the detainee needs admission to a psychiatric hospital. The forensic physician consults the second-line Public Mental Health Care (PMHC).

OBJECTIVE

This study aims to give an overview of the outcomes of psychiatric assessments of apparent mentally ill detainees in police stations. These assessments were done by forensic physicians over a period of eight years (2005-2013). A distinction is made between mental disorders, social problems, and alcohol/drugs abuse.

METHODS

All psychiatric assessments were registered in a medical database. When a secondary public mental health care assessment was performed, the conclusions and/or written feedback were received and included in the medical database. This information was used for this retrospective observational study.

RESULTS

Of all the apparent mentally ill individuals brought by the police into the police station, the forensic physician sent home or referred 51.8% to their own respective caretakers or the individuals were voluntarily admitted to addiction care or other care facilities. When the forensic physician referred a detainee to PMHC, a compulsory admission to a psychiatric hospital was indicated by PMHC in 62.8% of the cases. Ultimately, of the total apparent mentally ill individuals brought in by the police 30.0% was admitted to a psychiatric hospital.

DISCUSSION

Many apparent mentally ill individuals brought to the police station are sent home by the forensic physician. Before the psychiatric assessment, medical causes of psychiatric illnesses, for example excited delirium syndrome and hypoglycemia, drug use (GHB, cocaine, heroin), and cerebral pathology are excluded. The police perform as one of the channels through which the mentally ill get entrance to mental health care. Our data show no changes in the number of psychiatric assessments during 2005-2013.

Blunt Craniofacial Trauma as a Manifestation of Excited Delirium Caused by New Psychoactive Substances

The body of a 19-year-old male was found apparently concealed underneath bushes with recent head and facial trauma, and multiple superficial abrasions. Subsequently, it was discovered that the decedent had been running into objects and buildings following the ingestion the evening before of what was thought to be lysergic acid diethylamide (LSD). Blood staining of a nearby wall close to where the body was lying was in keeping with the described behavior. Toxicology revealed 3,4-methylenedioxymethamphetamine (Ecstasy), in addition to two only recently available drugs 2-(4-bromo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine, (25B-NBOMe), and 1-(3,4-methylenedioxyphenyl)-2-(1-pyrrolidinyl)-1-butanone, (MDPBP). At autopsy, the skull was fractured with cerebral swelling, contusions, and subarachnoid hemorrhage. Death was due to blunt cranial trauma against a background of mixed drug toxicity. The case demonstrates a rare cause of death in a drug-induced acute delirium, as well as highlighting two new designer street drugs that may result in significant aberrant behavior.

Excited delirium: A psychiatric review

The term 'excited delirium' (ED) is used to explain sudden and unexpected restraint-related deaths. Since the 1990s, ED has often been identified as the principal cause of death in restrained individuals, rather than the restraint procedure itself. Forensic pathologists and psychiatrists attach different meanings to the term delirium. For psychiatrists, delirium is a specific technical term, which implies a grave and potentially life-threatening underlying physical illness. If a patient dies during a bout of delirium, psychiatrists assume that there will be autopsy evidence to demonstrate the primary underlying organic cause. Conversely, pathologists appear to be using the term ED to refer to restraint-related deaths in either highly disturbed cocaine users or psychiatric patients in a state of extreme agitation. In these cases, there is no underlying physical disorder other than a terminal cardiac arrhythmia. As the term ED has different meanings for psychiatrists and for pathologists, it would be helpful for these two professional groups to develop a mutually agreed terminology.

Altered mental status and end organ damage associated with the use of gacyclidine: a case series

INTRODUCTION

Over the past decade, there has been a sharp increase in the number of newly identified synthetic drugs. These new drugs are often derivatives of previously abused substances but have unpredictable toxicity. One of these drugs is gacyclidine, a derivative of phencyclidine (PCP). Gacyclidine has been studied as a neuroprotective agent in trauma and as a therapy of soman toxicity. There are no previous reports of its use as a drug of abuse.

CASE REPORTS

During a two-month period in the summer of 2013, a series of patients with severe agitation and end-organ injury were identified in an urban academic Emergency Department (ED). A urine drug of abuse screen was performed on all patients, and serum samples were sent for comprehensive toxicology analysis. A total of five patients were identified as having agitation, rhabdomyolysis, and elevated troponin (Table 1). Three of the five patients reported use of methamphetamine, and all five patients had urine drug screens positive for amphetamine. Comprehensive serum analysis identified methamphetamine in three cases, cocaine metabolites in one case, and a potential untargeted match for gacyclidine in all five cases. No other drugs of abuse were identified.

DISCUSSION

This is the first series of cases describing possible gacyclidine intoxication. The possible source of the gacyclidine is unknown but it may have been an adulterant in methamphetamine as all patients who were questioned reported methamphetamine use. These cases highlight the importance of screening for new drugs of abuse when patients present with atypical or severe symptoms. Gacyclidine has the potential to become a drug of abuse both by itself and in conjunction with other agents and toxicity from gacyclidine can be severe. It is the role of the medical toxicology field to identify new agents such as gacyclidine early and to attempt to educate the community on the dangers of these new drugs of abuse.

Investigation of Deaths Temporally Associated with Law Enforcement Apprehension

The investigation of a death that occurs in custody requires a careful and methodical approach since concerns of police or institutional misconduct may be raised. The medicolegal official charged with the investigation and ultimate certification of death bears heavy responsibility to the decedent's family, the public, law enforcement and other institutions. A wide variety of causes of death and manners of death are seen in these deaths. This paper reviews causes, mechanisms, manners, findings, and evaluation of persons who have died in temporal relation to legal apprehension.