Excited delirium

EXD has been accepted by the American College of Emergency Physicians, who argue in a 2009 white paper that "excited delirium" may be described by several codes within the ICD-9.[6] A November 2012 The Journal of Emergency Medicine literature review says that the American College of Emergency Physicians Task Force reached consensus, based on "available evidence, that Excited Delirium Syndrome (EDS) is a "real syndrome with uncertain, likely multiple, etiologies."[1]

According to one 2020 publication, "excited delirium syndrome" is a "clinical diagnosis" with symptoms including delirium, psychomotor agitation, and hyperadrenergic autonomic dysfunction.[7]

The diagnosis was not in the 2013 Diagnostic and Statistical Manual of Mental Disorders-5 or the 1992 International Classification of Diseases.[1][8]

Treatment initially may include ketamine or midazolam and haloperidol injected into a muscle to sedate the person.[2] Rapid cooling may be required in those with high body temperature.[1] Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful.[1] One of the benefits of ketamine is its rapid onset of action.[9] The risk of death among those affected is less than 10%.[1] If death occurs it is typically sudden and cardiac in nature.[1] Concern has been raised by some medical professionals about the increasing usage of a claim of excited delirium to justify tranquilizing persons during arrest, with requests for tranquilization often being made by law enforcement rather than medical professionals. Ketamine is the most commonly used drug in these cases.[10]

How frequently cases occur is unknown.[1] Males account for more documented diagnoses than females.[11] Deaths associated with the condition are typically males with an average age of 36.[1] Often law enforcement has used tasers or physical measures in these cases, and death most frequently occurs after the person is forcefully restrained.[1]

The signs and symptoms for excited delirium may include:[12][13][14][15]

• Severe panic or distress, often exhibiting paranoia
• Disorientation
• Dissociation
• Aggressiveness and combativeness
• Fast heart rate
• Hallucination
• Diaphoresis (profuse sweating)
• Incoherent speech or shouting
• Unexpected strength (typically while trying to resist restraint)
• Hyperthermia (overheating)
• Inappropriately clothed e.g. having removed garments

Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV.[6][16][17] Alcohol withdrawal or head trauma may also contribute to the condition.[13] Physical struggle, especially if prolonged, has been shown to greatly exacerbate many of the harmful symptoms such as metabolic acidosis, hyperthermia, catecholamine surge, and tachycardia.[1] A majority of fatal cases involved men in a law enforcement or restraint situation.[1]

People with excited delirium frequently have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine.[12] Other drugs that may contribute to death are antipsychotics.[18][19][20]

The cause is often related to long-term drug use or mental illness.[1] Commonly involved drugs include cocaine, methamphetamine, or certain substituted cathinones.[3] In those with mental illness, rapidly stopping medications such as antipsychotics may trigger the condition.[1]

The pathophysiology of excited delirium is unclear,[14] but likely involves multiple factors.[21] These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal abnormal heart rhythms.[21] The underlying mechanism may involve dysfunction of the dopamine system in the brain.[3]

Key signs of excited delirium are aggression, altered mental status, and diaphoresis/hyperthermia.[22]

Other conditions which can resemble excited delirium are mania, neuroleptic malignant syndrome, hypoglycemia, thyroid storm, and catatonia of the malignant or excited type.[23][22]

In 1849 a similar condition was described by Luther Bell as "Bell's mania".[1][24] The first use of the term "excited delirium" (EXD) was in a 1985 Journal of Forensic Sciences article, co-authored by coroner, Charles V. Wetli, entitled "Cocaine-induced psychosis and sudden death in recreational cocaine users".[25][26][1] The JFS article reported that in "five of the seven" cases they studied, deaths occurred while in police custody.[26]

The condition is not recognized by the American Psychiatric Association, American Medical Association or the World Health Organization.[27][28][29] Critics of excited delirium have stated that the condition is primarily attributed to deaths while in the custody of law enforcement and is disproportionately applied to black and Hispanic victims.[27][30][31] Eric Balaban of the American Civil Liberties Union argued in 2007 that the diagnosis served "as a means of white-washing what may be excessive use of force and inappropriate use of control techniques by officers during an arrest."[4]

• Taser safety issues
• Adrenergic storm
• Sudden unexpected death syndrome
• Delirium tremens
• Stimulant psychosis