It is 5:00 pm on a Saturday night, and Mr. Suarez arrives at Booking where you are working tonight in the County Jail in the custody of four Deputies. The Deputies tell you that he was picked up at the train station because he was “acting crazy”, pulling his clothes off and screaming that he “did not want to go”. They tell you that he has been on a methamphetamine binge since Thursday morning according to his girlfriend, who was at the train station trying to get him to come back home. The Deputies were called when bystanders were concerned for her safety. Security orders the use of the Restraint chair per their policy, and you are the nurse standing by to perform the post-restraint evaluation. Mr. Suarez continues to struggle with the Deputies, showing almost superhuman strength. The Deputies use the taser on Mr. Suarez, but he is oblivious to the pain. The Deputies finally get Mr. Suarez restrained, and he stops struggling. You approach him with caution, ready to complete your nursing assessment. You speak to Mr. Suarez, but he does not respond. His head is back in the chair. You attempt to obtain a pulse, and palpate none. His skin is extremely hot. You auscultate for an apical rate, and there is none. You tell the Deputies to get Mr. Suarez out of the restraint chair and call 911. Cardiopulmonary resuscitation is initiated, but Mr. Suarez is pronounced dead in the Emergency Department. The autopsy shows no apparent physical cause of death.
You have just witnessed the medical emergency known as Excited Delirium.
Excited Delirium
Excited Delirium is a rare but deadly condition that can confront nurses working in corrections – particularly jails. While the exact etiology of Excited Delirium is still unknown, incidents have been documented in scientific literature since the 1800’s. There have been many incidents of Excited Delirium in the correctional environment, and it is important that healthcare staff are able to recognize the symptoms and appropriately transfer the individual to an Emergency Department.
Causes of Excited Delirium
Research is showing that Excited Delirium is the result of a neural chemical imbalance in the brain. A prevailing theory is that Excited Delirium is caused by overstimulation of the brain by dopamine. Cocaine, narcotics or extreme stress can cause an increase in dopamine release. Another biomarker under study is the release of heat shock proteins that leads to problems with body heat. The person’s body temperature rises rapidly without regulation. This combination overpowers the heart and respiratory systems leading to sudden death.
What does Excited Delirium Look Like?
The challenge of Excited Delirium in the correctional environment is to quickly identify that there is a medical condition underlying what seems like a behavioral issue that needs to be addressed. An individual in the throes of Excited Delirium will seem superhumanly strong and intensely hysterical, resisting all attempts at restraint. Often the individual is pulling off clothing to reduce the overheating. They often seem oblivious to pain and have little response to tasers and pepper spray.
Phases of Excited Delirium
Phase One: Hyperthermia
Hyperthermia is a critical condition which occurs when the body absorbs or produces more heat than it can dissipate. Often the individual begins to strip off their clothes as their core temperature is elevated to 103° – 113° F. Profuse sweating may indicate a high core body temperature, but may not always be present.
Phase Two: Delirium
The second phase occurs when the individual exhibits delirium with agitation. They often have superhuman strength. Usually they have a sudden decrease in attention, perception and focus.
Phase Three: Respiratory Compromise
This phase is often noticed during a struggle or restraint situation, or immediately after. It is believed that the physical struggle causes the body to require an increased level of oxygen which is not available. Respiratory compromise and arrest may occur secondary to this increased oxygen need. This is a medical emergency.
Phase Four: Cardiac Arrest
Cardiac arrest is the sudden loss of heart function. In this situation, death occurs in moments unless cardiopulmonary resuscitation is immediately initiated. The presence or absence of a diagnosed heart condition has little bearing on the outcome.
Nursing INterventions
Nursing interventions include calling EMS and getting the individual transported to the nearest emergency department for aggressive management as soon as any of the symptoms are observed, and preparing to initiate cardiopulmonary resuscitation should that be necessary.
The information for this post comes from The Correctional Nurse Educator class Excited Delirium for the Correctional Nurse.
Have you had an experience with excited delirium? Share it in the comments section for this post.
JEFFREY L METZNER says
Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts
Approved by the Board of Trustees, December 2020
Approved by the Assembly, November 2020
“Policy documents are approved by the APA Assembly and Board of Trustees. . . These are . . . position statements that define APA official policy on specific subjects. . .” – APA Operations Manual
Issue:
As noted in the APA’s Position Statement on Police Interactions with Persons with Mental Illness (2017),in a range of crisis situations, law enforcement officers are called as first responders and may find individuals who are agitated, disorganized and/or behaving erratically. Such behaviors may be due to mental illness, intellectual or developmental disabilities, neurocognitive disorders, substance use, or extreme emotional states. Police responses to calls for behavioral health crises have been known to result in tragic outcomes, including injury or death. The concept of “excited delirium” (also referred to as “excited delirium syndrome (ExDs)”) has been invoked in a number of cases to explain or justify injury or death to individuals in police custody, and the term excited delirium is disproportionately applied to Black men in police custody. Although the American College of Emergency Physicians has explicitly recognized excited delirium as a medical condition, the criteria are unclear and to date there have been no rigorous studies validating excited delirium as a medical diagnosis. APA has not recognized excited delirium as a
mental disorder, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM5). The DSM-5 recognizes Delirium, hyperactive type, but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium (e.g., superhuman strength, impervious to pain, etc.). Recent data suggest that persons being detained by the police and described as having “excited delirium” have frequently received medication from emergency medical technicians (EMTs) intended to rapidly sedate them. Ketamine, an FDA-approved medication for anesthesia is often used for this purpose. In some reported cases, it is questionable whether the person identified as having an
“excited delirium” actually had any medical condition warranting its use. Many sedating medications, used in outside of hospital contexts, including ketamine, have significant risks, including respiratory suppression. Supporting respiration may be challenging outside of a hospital setting, where it may require intensive medical oversight or involvement.
APA Position:
It is the position of the American Psychiatric Association that acute medical conditions, including Delirium, always require an appropriate medical response. Therefore, it is the position of the APA that:
1. The term “excited delirium” (ExDs) is too non-specific to meaningfully describe and convey information about a person. “Excited delirium” should not be used until a clear set of diagnostic criteria are validated.
© Copyright, American Psychiatric Association, all rights reserved.
2. An investigation should be undertaken of cases labelled with “excited delirium” to identify how the term is being used, whether consistent criteria are being applied, and whether it has any validity as a medical syndrome. The U.S. Department of Health and Human Services should
conduct a comprehensive, nationwide investigation of instances in which individuals have been identified as being in a state of excited delirium, including in interactions with law enforcement personnel and other out-of-hospital contexts. The study should include examination of all
relevant data, including the precipitating events, health outcomes for the individuals and law enforcement personnel, and whether there is a disproportionate application of the term “excited delirium” to persons with mental illness, Black people, or other racial and ethnic groups.
3. All jurisdictions should develop, implement, and routinely update evidence-based protocols for the administration of ketamine and other sedating medications in emergency medical contexts outside the hospital. These protocols should allow use of these medications only for treatment
purposes in medically appropriate situations and should explicitly bar their use to achieve incapacitation solely for law enforcement purposes.
Author: Council on Psychiatry and Law
Lori Roscoe says
Dr. Metzner – thank you so much for sharing the APA’s 2020 position statement on the use of the term “Excited Delirium” and appropriate medical management of out-of-hospital contexts.