62
Review, Clinical Update, and Practice Guidelines
for Excited Delirium Syndrome
Kevin B. Gerold, DO, JD; Mark E. Gibbons, EMT-P;
Richard E. Fisette Jr, PA; Donald Alves, MD
ABSTRACT
Excited delirium syndrome (ExDS) is a term used to
describe patients experiencing a clinical condition characterized
by bizarre and aggressive behavior, often in association
with the use of chronic sympathomimetic drug
abuse. The agitated and disruptive behavior of persons
with ExDS often results in a call to police resulting in
an arrest for disorderly conduct. The suspect’s inability
to comply with police commands during the arrest frequently
results in a struggle and the use of physical or
chemical control measures, including the use of conductive
energy weapons (CEWs). Deaths from this hypermetabolic
syndrome are infrequent but potentially preventable
with early identification, a coordinated aggressive police
intervention, and prompt medical care. Preliminary experiences
suggest that ExDS is a medical emergency treated
most effectively using a coordinated response between
police officers and emergency medical providers. Once
the person suspected of experiencing ExDS is in custody,
medical providers should rapidly sedate noncompliant
patients with medications such as ketamine or an antipsychotic
drug such as haloperidol in combination with
a benzodiazepine drug such as midazolam or diazepam.
Once sedated, patients should undergo a screening medical
assessment and undergo initial treatment for conditions
such as hyperthermia and dehydration. All patients
exhibiting signs of ExDS should be transported rapidly
to a medical treatment facility for further evaluation and
treatment. This article reviews the epidemiology, clinical
presentation, diagnosis, and treatment options for ExDS.
Keywords: excited delirium, excited delirium syndrome,
delirium, sudden death, in-custody death, hyperthermia,
sympathomimetic drug use, cocaine, phencyclidine, lysergic
acid diethylamide, ketamine, haloperidol, TASER, conductive
energy weapon, Agitated Chaotic Event™
, ACE, medical
emergency, emergency medical services, police
Introduction
ExDS is a term first attributed to the Miami Medical Examiner’s
Office in 1985. It was used to describe a class of
patients who experienced bizarre and aggressive behavior
in association with an altered mental status, often in
combination with other symptoms that included disrobing
or wearing clothing inappropriate for conditions,
failing to comply with verbal commands by police, yelling
or making guttural sounds, attacking inanimate objects,
attraction to light, and a propensity to break glass.
When attempts were made to restrain these individuals,
they often exhibited “superhuman” strength and
an unwillingness to yield despite overwhelming force.
One study reported that four officers were on average
required to subdue these individuals (range 3–6).
Police officers must continually adapt to changing
threats that include contact with emotionally unstable
and potentially violent individuals, often in association
with mental illness or drug abuse. When these individuals
violate the law and fail to comply with lawful orders,
police officers and citizens are placed at risk for physical
harm during and unfolding, dynamic, and potentially
life-threatening encounter. Police and medical practitioners
are increasingly recognizing these types of encounters
as medical emergencies that require the education
and training of police officers, emergency medical services
(EMS) responders, and hospital staff in how best
to manage these encounters effectively.
Medical experts continue to disagree about whether
ExDS is a unique medical condition warranting its own
diagnosis or is a variant of an existing psychiatric disorder.
Those advocating that ExDS is a unique condition
note that it occurs in susceptible individuals in association
with the use of stimulants, especially cocaine,
though cases have occurred in association with methamphetamine,
PCP, and LSD. Cocaine use is known to cause
increases brain levels of the neurotransmitters dopamine
and serotonin. Increased levels of these neurotransmitters
are responsible for the addictive properties of this
drug and contribute to hyperactivity and hyperthermia.
Chronic cocaine use induces a physiologic change in
the regulation of dopamine and serotonin, which may
be neuroprotective. Persons who experience ExDS may
have an unusual genotype or phenotype that prevents
Excited Delirium Syndrome	 63
the protective adaptation to cocaine use. This failure
to alter neurotransmitter regulation to cocaine or other
stimulant use results in high dopamine levels and a hyperactive
autonomic nervous system, which may predispose
to ExDS.1
The American College of Emergency Physicians (ACEP)
and the National Association of Medical Examiners
(NAME) recognize ExDS as a unique clinical syndrome.
The American Medical Association (AMA) and the
American Psychiatric Association (APA) do not, and it is
not listed in the International Classifications of Disease,
Ninth Revision (ICD-9). Under existing ICD-9 codes,
ExDS can be classified as 296.00S Manic Excitement;
293.1J Delirium of Mixed Origin; 292.81Q Delirium,
drug induced; 292.81R Delirium, induced by drug;
307.9AD Agitation; 780.09E Delirium; 799.2AM Psychomotor
Excitement; 799.2V Psychomotor Agitation;
or 799.2X Abnormal Excitement. The upcoming ICD-
10 is also without a specific ExDS code, relying instead
on the F10–F19 group of Mental and Behavioral Disorders
due to Psychoactive Substance Use or F43 Reaction
to Severe Stress, and Adjustment Disorders.
History of Police In-custody
Deaths and Excited Delirium
In-custody deaths always evoke controversy. Deaths incustody
from undetermined causes typically occur suddenly
and unexpectedly, and autopsy findings provide
minimal physical findings to explain it. This unexpected
nature of these events and the absence of objective evidence
supporting a clear cause of death challenge the
reputations of police departments and strain relations
within their community. Allegations of police brutality
and conspiracy to conceal police activities frequently
occur. and some have asserted that ExDS is a hoax to
cover up the inherent dangers of CEWs (TASER).2
Law
enforcement and correctional officers involved in such
events are frequently stigmatized and experience professional
pressure and personal stress.
Investigations into in-custody deaths occurring over the
past two decades have concluded that these occurrences
are very rare. Since the 1990s, the majority of in-custody
deaths arise from an undetermined cause. Most occur in
association with a series of factors that include a history
of stimulant use, a struggle, the use of restraints, and the
existence of coexisting disease. When combined, the result
can be sudden death.3
Many of the previously unexplained
in-custody deaths are now attributed to ExDS.
ExDS is not a new medical condition. A chronic form
of ExDS was observed commonly in psychiatric institutions
from 1850 to 1950. Originally termed lethal
or malignant catatonia, Bell’s mania, manic delirium,
exhaustion death, exhaustion psychosis, fulminating
psychosis, and ­exhaustive syndrome, this condition affected
­predominantly women with psychiatric disor­
ders.4
These patients presented with agitation, anorexia
(lack of appetite), fever, and increasing confusion. Mortality
occurred in 75% to 100% of cases, and death
was attributed to exhaustion. With the introduction of
antipsychotic medications such as chlorpromazine and
haloperidol, this condition virtually disappeared until
the 1980s, when it reemerged as an acute form in association
with stimulant use, primarily cocaine, methamphetamine,
and phencyclidine.
In a historical analysis of death in custody, Grant and
colleagues conducted a retrospective review spanning 34
years. The Maryland Office of the Chief Medical Examiner
reviewed a cohort of 145,425 cases occurring between
1939 and 2004. From their review, they were able
to identify only 202 (0.14%) in-custody deaths.5
They
concluded that cardiovascular disease was the most
common cause of in-custody deaths until the 1970s,
except for the 1940s, where the primary causes of incustody
death was due to complications from syphilis
and tuberculosis. Suicide while in custody predominated
in the 1980s, with 44% due to hanging.
“Undetermined” as a cause of death emerged in the
1980s and became the dominant cause of death from
the 1990s. Most of these deaths were attributed to
drug intoxication involving cocaine (36%) and narcotics
(31%). The authors concluded that death while
in-­custody was rare historically, that death from undermined
causes did not emerge until the 1980s, and
that death from an undetermined cause accounts for the
majority of in-custody deaths since 1990. The authors
suggested that unexpected death in custody coincided
with an increase in the abuse of stimulants. Within the
last few years, some have proposed abandoning the
term “excited delirium syndrome” in favor of “agitated
chaotic event™
” (ACE), a term that better describes this
condition and avoids the social stigma associated with
this condition.6
The same authors conducted a similar study attempting
to identify the frequency of in-custody ExDS deaths.
They performed a retrospective review of 353,029
deaths reviewed by the Maryland Office of the Chief
Medical Examiner spanning 1939 to 2005.7
The authors
identified 62 custodial death cases that listed
excited or agitated delirium as a cause of death and/
or who died while demonstrating characteristics associated
with ExDS. Of the 62 cases, 48 (77%) occurred
between 1980 and 2005. The mean age of the decedents
was 38 years (range 18 to 71 years). Ninety-four
percent were male, and 63% were African American.
Forty-one (66%) deaths occurred while in the custody
64	 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015
of law enforcement, 10 (16%) deaths occurred in a correctional
facility, and 11 (18%) deaths occurred in a
mental health facility. Physical restraints were used in 36
(58%). When physical restraint was required, 29 (81%)
occurred while in the custody of law enforcement. Toxicology
was positive in 37 (60%), negative in 17 (27%),
and not performed in 8 (13%).
Of those manifesting the signs of ExDS who died in
custody, death occurred typically within 1 hour of first
contact with the police. More than 75% of these persons
died at the scene or during initial transport.8
An
important sign of impending cardiopulmonary arrest
while in custody was the sudden and unpredicted cessation
of struggling against restraints.9
This cessation of
struggling has been termed the “period of peril.”10
During
this time, all resistance and exertion stop and the
subject appears calm. In the 2 to 5 minutes immediately
following intense activity, there is a surge in catecholamine
levels that may reach 10 times baseline levels.
High catecholamine levels can cause serum potassium
levels to fall as potassium moves into cells. This fall in
serum potassium may predispose these patients to cardiac
arrhythmias and sudden death.11
Safety of CEWs in Association With ExDS
Law enforcement officers increasingly use CEWs as an
effective intermediate use of force tool intended to induce
compliance with police commands and to affect an
arrest. The effectiveness of these weapons is evidenced
by a 10-year experience showing a reduced incidence of
injuries to suspects and police officers and a reduction
in claims for excessive force compared with other uses
of force techniques such as empty hand techniques and
use of a baton.12
A CEW in widespread police use is the TASER X26®
(Taser International; www.taser.com). When deployed,
it uses compressed nitrogen to fire two small probes
tethered by thin wires to distances of 25 feet, up to distances
of 35 feet. The weighted probes possess barbs
9mm in length designed to penetrate the skin or become
lodged on clothing. Each cartridge has a serial number
and, when deployed, leaves multiple identifiable tags at
the scene. When fired, the weapon delivers a 5-second
burst of approximately 400 volts (1,200 V peak), delivered
at a current of approximately 2.1 mA, and at
19 pulses per second.13
The device can also deliver an
open circuit voltage of up to 50,000 volts to conduct
across air or clothing. When the contact distance between
probes exceeds 4 inches, neuromuscular incapacitation
occurs through the activation of type A-α motor
neurons that control skeletal muscle contraction. Maximum
incapacitation occurs when probe spread exceeds
9 to 12 inches.14
When the distance between probes is
small (less than 4 inches) or when used in “drive stun”
mode, the device is intended to induce compliance by
producing pain without neuromuscular incapacitation.
The perceptions of pain, discomfort, and sensory overload
occur from the activation of type III A-δ myelinated
sensory fibers.15
Despite the relative safety of CEWs observed during
more than 2 million probe deployments during operations
and in training, there remains concern that these
weapons may contribute to the sudden death associated
with ExDS. 16
In a study of 1,201 cases of suspects subjected
to the use of TASER, 99.75% had no significant
injuries.17
A Canadian study in 2008 identified 326
deaths in North America associated with TASER use
from media reports and independent research, 20 of
which occurred in Canada.18
The authors noted that this
statistic did not, by itself, establish a causal relationship
between the use of a TASER and sudden death. More
recently, a panel of medical experts was convened in
Canada to conduct an independent evaluation of existing
research aimed at examining the medical and physiological
impacts of CEWs.19
They noted in their report:
•	 “Some animal studies suggest CEWs can induce fatal
cardiac arrhythmias (abnormal heart rhythm) when a
number of discharge characteristics, either alone or in
combination, are in place: probe placement on opposite
sides of the heart (i.e., current is delivered across
the heart), probes embedded deeply near the heart,
increased charge, prolonged discharges, or repeated
discharges. These studies indicate the biological plausibility
of adverse health outcomes following CEW
exposure.
•	 A small number of human cases have found a temporal
relationship between CEWs and fatal cardiac
arrhythmias, but available evidence does not allow
for confirmation or exclusion of a causal link. If a
causal link does exist, the likelihood of a fatal cardiac
arrhythmia occurring would be low, but further evidence
is required to confirm the presence and magnitude
of any risk.
•	 The roles of co-factors common to real-world CEW
incidents (e.g., intoxication, exertion, restraint) and
other co-factors (e.g., body type, existing health complications)
that may increase susceptibility to adverse
effects have not been adequately tested to properly
establish an understanding of increased vulnerability
in humans.”
While some studies have produced results implicating
that CEWs could potentially contribute to in-custody
death, large-scale prospective studies involving human
subjects exposed to CEWs for up to 15 seconds
have failed to demonstrate any clear causal relationship
between TASER use and laboratory abnormalities,
Excited Delirium Syndrome	 65
physiologic changes, cardiac arrhythmias, or myocardial
ischemia.19
Advocates for the use of CEWs further
­argue that these weapons reduce injuries to suspects
and police officers by terminating situations that might
otherwise culminate in sudden in-custody death in association
with ExDS.
Despite ongoing arguments for and against the safety
of CEWs, the scientific evidence remains insufficient to
determine whether the use of CEWs increases the probability
of sudden in-custody death in the presence of cofactors
such as mental illness or ExDS. However, it is
reasonable to conclude that the weapon’s proven effectiveness
in inducing compliance and promoting officer
safety outweighs concerns for the minimal likelihood
that a CEW will be the sole cause of a sudden in-custody
death. Further research is needed in order to more fully
determine whether there is a causal association between
CEW use and in-custody death. Until future investigations
are able to clarify this concern, police officers and
medical practitioners should assume that persons exposed
to a CEW discharge exceeding a cumulative exposure
of 15 seconds, especially when used in association
with prolonged struggling, altered mental status, and
suspected drug intoxication, are experiencing ExDS and
promptly refer these individuals for medical evaluation
and treatment.20
The Model Electronic Control Weapons
(ECW) Policy from the International Association of
Chiefs of Police (IACP) advocates a medical evaluation
for persons subjected to a CEW when, “he or she has
been exposed to more than three ECW cycles, . . . exposed
to the effects of more than one ECW device, . . .
believed to have been exposed to a continuous cycle of
15 seconds or more, . . . [or] exhibits signs of ‘excited
delirium.’”21
Diagnosis of ExDS
While there is no uniform definition of ExDS, this syndrome
should be suspected in any individual exhibiting
abnormal behavior including agitation and six or more
of 10 criteria identified by Hall et al.22
In their study of
more than 1 million police encounters during a 2-year
period, they identified features associated with ExDS.
These included a high tolerance to pain, tachypnea,
sweating, agitation, hyperthermia to touch, noncompliance
with police commands, absence of fatigue, unusual
strength, dressing inappropriately for conditions,
and an attraction to mirrors or glass (see Tables 1 and
2 for a list of differential diagnoses and ExDS criteria).
Police officers and medical personal should have an additional
heightened suspicion for ExDS whenever the
person exhibiting signs of ExDS is male (mean age 36
years) or is suspected of using or withdrawing from the
use of stimulants, such as methamphetamine, PCP, LSD,
and especially cocaine. The National Institute of Justice
Technology Working Group on Less Lethal Devices has
prepared an Excited Delirium pocket card useful for police
officers and EMS responders (Figure 1). 23
Treatment of ExDS
The priorities for the initial treatment of patients with
ExDS are control and restraint, rapid sedation, and
transport to a hospital for definitive care. In the absence
of clinical studies on the best treatment for this potentially
lethal condition, clinicians must rely on consensusdriven
guidelines.
The appropriate response to patients with ExDS should
begin with dispatch. When an operator receives a call
involving someone manifesting signs of ExDS, the call
center should simultaneously dispatch law enforcement
and EMS teams.24
First responding EMS units should
stage at a safe location until police officers have evaluated
the call and rendered conditions safe for EMS to
Table 1 Differential Diagnosis of Excited Delirium
Differential Diagnosis of Excited Delirium
Drug or alcohol intoxication
Drug or alcohol withdrawal
Hypoxemia
Electrolyte disorder
Thyroid storm
Sepsis
Seizure disorder
Traumatic brain injury
Heat stroke
Serotonin syndrome
Neuroleptic malignant syndrome
Table 2 Features Associated With Excited Delirium Syndrome
Feature
Frequency, %
(95% confidence interval)
Tolerance to pain 100 (83–100)
Tachypnea 100 (83–100)
Sweating 95 (75–100)
Agitation 95 (75–100)
Hyperthermia to touch 95 (75–100)
Noncompliance to police
commands
90 (68–99)
Lack of tiring 90 (68–90)
Unusual strength 90 (68–90)
Dressed inappropriately for
environment
70 (45–88)
Attraction to mirrors or glass 10 (not reported)
66	 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015
­enter and render care. Dispatchers should also ensure
that an adequate number of police officers are dispatched
to safely control the situation. As discussed
previously, an average of four officers is required to effectively
achieve control of a typical suspect with ExDS.
First arriving officers responding to a disturbance of
the public peace or disorderly conduct should initially
assess individuals for indicators of ExDS. If signs of
ExDS are present, then officers should take into consideration
that the subject may be irrational, potentially
violent, and dangerous. The law enforcement objectives
of initially responding officers are to protect the public
and the suspect from harm and contain the suspect until
additional police and EMS resources arrive. If EMS
has not been dispatched, then officers should request
that they respond. If possible, first responding officers
should contain the disturbance and employ deescalation
techniques and minimize unnecessary stimuli that can
further excite or provoke the suspect. Deescalation techniques
include avoiding the use of emergency equipment
(lights and sirens) and of canines and not shouting at the
suspect, all of which may escalate an unstable situation.
Persons with ExDS may not understand and comply
with verbal commands and may resist usually effective
control tactics such as pepper spray, impact batons, joint
locks, kicks, and punches.25
Officers must acknowledge
that subjects manifesting signs of ExDS are experiencing
an acute, potentially life-threatening condition.
Forceful restraint is nearly always required in ExDS.
Once the necessary police and EMS resources are in
place, suspects failing to respond to verbal commands
and resist arrest should be taken into custody quickly
and efficiently in a manner that minimizes a struggle. In
many instances, inducing neuromuscular incapacitation
with a CEW may be the safest and most efficient manner
to achieve control. While there is no medical evidence to
suggest that prone or supine restraints have any detrimental
effects on these individuals,9
minute ventilation
is generally above normal and officers should assess for
respiratory distress. If present, the officer should place
the suspect in a position that does not restrict breathing.
Breathing is least affected by placing the individual on his
side in the recovery position. Once police officers achieve
physical control and disarm the suspect of any weapons,
EMS providers should be permitted to conduct a medical
survey, administer sedation to reduce struggling, if
needed, and initiate resuscitative measures as indicated.
Patients who continue to resist despite with verbal calming
and deescalation techniques should be sedated because
continuing to struggle with physical restraint is
associated with a high risk for sudden death, particularly
Figure 1 National Institute of Justice Pocket Reference Card on Excited Delirium.
Excited Delirium Syndrome	 67
in persons who are obese, under the influence of stimulant
drugs, and have underlying medical disease.26
The
ideal medication for this purpose would be administered
intramuscularly (IM) or intranasally (IN), have a rapid
onset of action, be of short duration, be effective on most
agitated or violent persons, and be free of hemodynamic
instability and respiratory depression. While a medication
meeting all these criteria does not exist, sedation can be
accomplished by administering benzodiazepines, antipsychotics,
or a dissociative agent such as ketamine (Table 3).
Table 3 Medications Useful to Treat Acute Excited Delirium
Medication
Route of
Administration
Typical
Dose, mg
Onset,
min
Duration,
min
Midazolam
IN
IM
IV
5
5
2–5
3–5
10–15
1–5
30–60
120–360
30–60
Lorazepam
IM
IV
4
2–4
15–30
2–5
60–120
60–120
Diazepam IV 5–10 2–5 15–60
Haloperidol
IM
IV
10–20
5–10
15–30
10
180–360
180–360
Ketamine
IM
IV
4–5mg/kg
2–4mg/kg
3–5
1
60–90
20–30
Note: IM, intramuscular; IN, intranasal; IV, intravenous.
Ketamine is an anesthetic administered by intravenous or
intramuscular injection to stimulate N-methyl-d-aspartate
(NMDA) receptors producing analgesia and a dissociative
state. This drug preserves airway reflexes and does
not suppress ventilation. Case reports describe excellent
clinical results with an overall reduction in the hyper
adrenergic state.27–29
Side effects of this drug include salivation,
laryngospasm, and emergence delirium.30
These
side effects appear less common with the subanesthetic
doses used to treat ExDS. Earlier concerns for increasing
intracranial pressure in traumatic brain injury have been
discounted.31
Benzodiazepine medications useful in the treatment of
ExDS include lorazepam, midazolam, and diazepam.
Benzodiazepine drugs act on the γ-aminobutyric acid
(GABA) receptors; the main inhibitory neurotransmitters
in the brain. These medications may be given orally
(PO) or via IM, intravenous (IV), or intraosseous (IO)
injection. Midazolam can also be administered via the
IN route. When administered IM, the onset is slow and
the drug may interact with other medications to cause
respiratory depression and hypotension. Administering
benzodiazepine drugs by serial IV doses and titrating to
effect are preferred to other routes in order to achieve
the desired effects without incurring oversedation.
Antipsychotic medications, such as haloperidol, bind to
dopamine receptors in the brain to produce sedation. Administered
PO, IM, or IV, antipsychotic medications have
a long history of safety in patients with delirium. This class
of drugs may increase the QT-interval of the cardiac cycle,
which can give rise to ventricular arrhythmias, including
ventricular fibrillation and ventricular tachycardia. In
rare cases, antipsychotic medications can trigger the neuroleptic
malignant syndrome (NMS), resulting in hyperthermia.
The benefits of using antipsychotic medications
such as haloperidol in patients with ExDS generally outweigh
the low risk of medication side effects, particularly
when limited to a single dose for initial control.
In the absence of consensus on the best approach for
prehospital sedation, we must rely on anecdotal experience
by EMS providers. Recent experience suggests
that efforts at rapid sedation with haloperidol benzodiazepines
have been disappointing, and ketamine is
emerging as an increasingly popular chemical restraint
for the prehospital sedation of violent patients. Two recent
studies using ketamine for the prehospital sedation
of agitated or violent patients demonstrate that a single
IM dose of ketamine 4 to 5mg/kg is greater than 90%
effective in achieving effective behavior control with a
low incidence of side effects.32,33
Preliminary experiences
suggest that respiratory complications associated with
using ketamine are acceptably low and are more likely
to occur in association with higher doses, when combined
with midazolam, or with other prior drug use.31–33
It is unknown whether smaller doses would achieve a
similar degree of sedation or reduce drug side effects.
Once IV access is obtained, patients requiring further sedation
can receive additional doses of ketamine or other
drugs such as midazolam or haloperidol.
EMS providers must be prepared to aggressively evaluate
and initiate care to prevent ExDS patients from spiraling
into metabolic failure, which may progress to cardiac
arrest. As soon as safely possible, the patient should undergo
an initial assessment that includes monitoring of
vital signs, pulse oximetry, cardiac monitoring, glucose
measurement, and careful physical examination including
attention to breathing and skin temperature. Intravenous
access should be obtained when possible, and IV
fluids and supplemental oxygen should be administered,
if needed.23
Medical providers should assess all patients with ExDS
for hyperthermia. If the skin is hot to the touch, assume
hyperthermia and initiate active cooling methods such as
ice blankets, packing the head, neck, and groin with ice,
or instilling chilled IV fluids. Rectal temperature, while
diagnostic for hyperthermia, is not practical in this setting,
and other measures of determining core temperature
are unreliable.34
If IV access is not possible, patients
able and willing to drink can be cooled and hydrated
with chilled water or sports drinks, especially if there
will be an extended time to hospital evaluation and care.
68	 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015
Patients who comply with instructions and who are able
to sit or lie quietly are less likely to progress to more
severe forms of ExDS.
Patients with ExDS are likely dehydrated due to decreased
fluid intake and increased insensible losses from
high levels of activity, an increased core temperature,
hyperventilation, and diuresis. The administration of IV
fluids such as normal saline or balanced electrolyte solutions
such as lactated Ringer’s, Plasmalyte-A, or Normosol
can be used to correct dehydration and may prevent
or treat underlying electrolyte disorders and rhabdomyolysis.
There is no evidence that administration of sodium
bicarbonate affords any benefit in the treatment
of this condition or its complications. Intravenous fluids
may be administered at rates of 1 to 1.5mL/hr until resuscitated
and then no more than to 500mL/hr initially.
Patients with ExDS may have a coexisting cardiomyopathy
and may be at a theoretical risk for fluid overload
and congestive heart failure.35
Under circumstances
where transfer to a medical facility is delayed and urine
output and laboratory values are unmonitored, IV fluids
should be limited to 3 to 6 L/day. All patients exhibiting
signs of ExDS should be transported emergently to a
hospital for further evaluation and treatment.
Conclusion
ExDS is an uncommon but potentially life-threatening
medical condition that occurs in association with stimulant
use. It is characterized by bizarre and aggressive behavior
and an altered mental status and in combination
with other symptoms that include disrobing or wearing
clothing inappropriate for conditions, failing to respond
to verbal commands by police, yelling or making guttural
sounds, attacking inanimate objects, attraction to
light, and a propensity to break glass. When attempts
are made to restrain these individuals, they often exhibit
“superhuman” strength, and an unwillingness to yield
to overwhelming force.
Deaths from this syndrome are infrequent but potentially
preventable with early identification and a coordinated
aggressive police intervention and prompt medical care.
Preliminary experiences suggest that if in-custody suspects
continue to struggle, then medical providers should
rapidly sedate these patients with combinations of IM
ketamine or an antipsychotic drug such as haloperidol
and a benzodiazepine drug such as midazolam or diazepam
administered IV. Once sedated, patients should
undergo a more comprehensive medical assessment and
when necessary, treatment measures initiated for hyperthermia
and dehydration. All patients exhibiting signs
of ExDS should be transported rapidly to a medical
treatment facility for further evaluation and treatment.
Further research is needed to better understand the
etiology of this syndrome and to identify best practices
to threat it.
Disclosures
The authors have nothing to disclose.
References
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Dr Gerold is an associate professor in the Departments of Anesthesiology
and Critical Care Medicine, and Emergency Medicine,
Johns Hopkins School of Medicine, Baltimore, Maryland.
E-mail: kgerold@jhmi.edu.
Major (Ret) Gibbons is affiliated with the Maryland State
Police.
2LT Fisette is a Special Forces Medical Officer with the US
Army National Guard.
Dr Alves is a clinical associate with the Department of Emergency
Medicine, Johns Hopkins School of Medicine, Baltimore,
Maryland.
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