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Excited Delirium is N-O-T A C-R-I-M-E

Updated: Sep 22, 2020

2020 has been an unprecedented year in a multitude of areas when it comes to law enforcement. In this article we are going to explore the topic of excited delirium. This subject has come up in several recent high-profile cases, so I thought it would be good to identify what excited delirium is, what it is not, and how to best recognize and treat it at the law enforcement level.

Firstly, it is important to recognize that excited delirium is NOT classified as a disease. Excited delirium is officially recognized as a condition by the American Medical Association as well as the American College of Emergency Physicians. As many of you may be aware, controversy surrounding excited delirium has dated back for decades.

One of the better official definitions of excited delirium describes it as: “A state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional strength, and endurance without apparent fatigue.” That definition falls under one of my personal three rules of medicine which is: “90% of emergency medicine at the street level is common sense.” Chances are that you have either responded to this type of emergency, or that you have heard about this type of emergency. A helpful mnemonic to identify these types of responses is: N-O-T A C-R-I-M-E.

N – Naked (Taking off clothes and or sweating A LOT)

O – Objects (The person will act violently toward objects, especially glass or shiny objects)

T – Tough (Seemingly superhuman strength, insensitivity to pain, long endurance

A – Acute (Sudden onset. Witnesses will describe that the person “just snapped.”)

C – Confused (The person will often not know who they are, where they are, or why they are there)

R – Resistant (Can’t or refuses to follow commands)

I – Incoherent speech (Person is shouting, not making sense)

M – Mental health issues (The person will often have a history of mental health complications)

E – Early request for additional resources to include EMS, back-up, a supervisor, and ideally a CIT trained officer.

While it is easy to commonly associate excited delirium with illicit drug use, it is essential that you understand that drug use is only ONE cause of excited delirium. It can also be the result of mental illness, chemical imbalances within the brain, hyperthermia (heat stroke), substance withdrawal among other medical complications.

It is critically important to understand that people who are in an excited delirium state are experiencing a very dangerous medial emergency. When someone is in an excited delirium state, several adverse reactions are going on in the body. One of the best ways to think about what is going on is to picture someone standing on the gas pedal and on the brake pedal at the same time until the engine of the vehicle that they are in explodes. Physiologically, everyone’s body has an acid base balance of between 7.35 and 7.45. A person having an excited delirium episode begins to have a chemical reaction throughout the body called metabolic acidosis. Just as the body is very sensitive to changes in temperature (hypothermia OR hyperthermia), the body is also very sensitive to changes in the pH level.

Allow me to break down the previous paragraph using English. For those who hit the gym on a regular basis, imagine doing the most strenuous workout that you have ever done. Your muscles begin to feel sore. One of the reasons behind the soreness is because of a release of lactic acid. Additionally, as you increase your workout intensity, you breathe deeper and more rapidly. The respiratory system is one of the main systems that balances the acid levels within the body.

Now going back to the person in an excited delirium state. The vast majority of their muscles are working hard which in turn is dumping an excessive amount of lactic acid into the body. Energy creates heat which is why the person is becoming hyperthermic and is sweating profusely. The person is ventilating rapidly because the body is trying to balance the acid levels. The problem is that the respiratory system is maxed out. Ventilation is the MECHANICAL movement of air in and out of the body. RESPIRATION is the exchange of oxygen and carbon dioxide. Because the respiration system is taxed, ventilation is taking place, but respiration is severely diminished. This is another critical point to understand. This is why the patient/subject/suspect/person is stating that they can’t breathe. Yes, they are mechanically moving air, but the RESPIRATION is not taking place at near the capacity that it needs to balance the acid level within the body, therefore they are dying. It is also very important to note that the vast majority of people who experience excited delirium are not in peak physical condition, and their health history is very poor.

For a quick review, the person that is experiencing this excited delirium episode is experiencing hyperthermia, metabolic acidosis from the lactic acid buildup into the system, rhabdomyolysis (the breaking down of muscle tissue) AND they are experiencing respiratory issues. Physiologically, the literal worst set of events for this person’s body to experience at this point is a taser deployment (additional muscle contracture), fighting, and then being pinned onto the ground where expansion of the chest wall is restricted. Allow me to be perfectly clear! Officer safety, and the life safety of the public takes precedence.

If the person does not pose an immediate threat, and if they are unarmed this creates an opportunity for a preferable outcome. The following tips will drastically improve the situation for both the person experiencing excited delirium as well as the officers responding.

1. A unified response is absolutely key for this type of emergency. Detailed information from the dispatcher should prompt an almost automatic response of EMS, back-up officers, a supervisor, and a CIT trained officer.

2. Understand that these types of emergencies take TIME. Be patient. If the situation allows, try to keep a safe distance from the patient. Appoint ONE-point person that approaches and speaks with the patient. Speak to the patient in a calm and quiet manner. The goal is to gain voluntary cooperation. Have other officers on the scene gather a health AND a mental health history about the patient.

3. EMS should stage close enough to the scene that the paramedic can make the approach to the patient with law enforcement with a sedative. Quick note: ONLY the EMS personnel will make the determination on whether to use a sedative, and which sedative to use. Law enforcement CANNOT direct the EMS personnel to administer any drug to a patient.

4. If the person cannot be calmed down and the decision to capture the person is made, have a clear plan between law enforcement AND the paramedic as to how the take down will take place. Once the person is under control using a restraint control tactic, ONE officer should advise the paramedic that it is ok to move in to administer the sedative. The paramedic should announce that there is an open needle, and upon administration of the sedative, the paramedic should advise when they are clear from the patient to avoid a needle stick injury.

5. The most important step after the take down previously mentioned is to position the patient in a manner that will make it easiest for them to breathe. Do not restrict the stomach, and do not restrict the chest from fully expanding.

6. If for some reason there is not a medic immediately available after you have gotten the patient into custody, begin cooling the patient by placing icepacks under their armpits, in their groin area, and behind the neck.

Excited delirium is a complex issue that even today sparks debate between leading experts. I would like to thank Dr. Bill Worden (also a Deputy) for his heavy input into this article. Please feel free to ask any questions or add any comments in the comments section below.

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