Excited Delirium

Hunsaker, John C.; Crook, Shannon; Shields, Lisa B.E.

doi:10.1201/9780429188947-32

Cited by 3 publications

(6 citation statements)

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“…Often the subjects would be hyperthermic and sometimes they would manifest superhuman strength, requiring several officers to subdue them. Excited delirium has since been attributed to a broad array of stimulant drugs besides cocaine [10]. DiMaio declared that excited delirium describes a fatal syndrome involving an adrenergic storm that is refractory to treatment [11].…”

Section: Introductionmentioning

confidence: 99%

Prone restraint cardiac arrest in in‐custody and arrest‐related deaths

Weedn

Steinberg²,

Speth³

2022

Journal of Forensic Sciences

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We postulate that most atraumatic deaths during police restraint of subjects in the prone position are due to prone restraint cardiac arrest (PRCA), rather than from restraint asphyxia or a stress-induced cardiac condition, such as excited delirium. The prone position restricts ventilation and diminishes pulmonary perfusion. In the setting of a police encounter, metabolic demand will be high from anxiety, stress, excitement, physical struggle, and/or stimulant drugs, leading to metabolic acidosis and requiring significant hyperventilation.Although oxygen levels may be maintained, prolonged restraint in the prone position may result in an inability to adequately blow off CO 2 , causing blood pCO 2 levels to rise rapidly.The uncompensated metabolic acidosis (low pH) will eventually result in loss of myocyte contractility. The initial electrocardiogram rhythm will generally be either pulseless electrical activity (PEA) or asystole, indicating a noncardiac etiology, more consistent with PRCA and inconsistent with a primary role of any underlying cardiac pathology or stress-induced cardiac etiology. We point to two animal models: in one model rats unable to breathe deeply due to an external restraint die when their metabolic demand is increased, and in the other model, pressure on the chest of rats results in decreased venous return and cardiac arrest rather than death from asphyxia. We present two cases of subjects restrained in the prone position who went into cardiac arrest and had low pHs and initial PEA cardiac rhythms. Our cases demonstrate the danger of prone restraint and serve as examples of PRCA. K E Y W O R D Sprone restraint, in-custody deaths, arrest-related deaths (ARDs), police-involved deaths, restraint asphyxia, positional asphyxia, excited delirium, sudden cardiac death, metabolic acidosis, George Floyd, forensic pathology, autopsy Highlights• Prone restraint deaths result from metabolic acidosis, not hypoxic asphyxia.• Metabolic demand is increased by stimulant drugs, physical exertion, and stress.• Metabolic acidosis requires hyperventilation to "blow off" carbon dioxide (CO 2 ).• Prolonged restraint in the prone position may prevent adequate elimination of CO 2 .• An initial ECG rhythm of PEA or asystole after a cardiac arrest is generally inconsistent with a primary cardiac etiology.How to cite this article: Weedn V, Steinberg A, Speth P. Prone restraint cardiac arrest in in-custody and arrest-related deaths.

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Section: Introductionmentioning

confidence: 99%

Prone restraint cardiac arrest in in‐custody and arrest‐related deaths

Weedn

Steinberg²,

Speth³

2022

Journal of Forensic Sciences

View full text Add to dashboard Cite

show abstract

“…There are numerous etiologies for hyperactive delirium, including endocrine abnormalities, various intoxications and withdrawals, brain injury, and psychiatric illness (first described by Luther Bell in 1849). 3,28,49 For one caused by cocaine, it would be designated as cocaine-induced delirium, acute, hyperactive.…”

Section: Not a Medical Diagnosismentioning

confidence: 99%

“…Acute hyperactive delirium is potentially fatal. 2,3,7,18, What was once called a cocaine-induced excited delirium is medically a cocaine-induced acute hyperactive delirium. The latter shares the same pathophysiology and presentation but is described with sanctioned medical terminology.…”

Section: Not a Medical Diagnosismentioning

confidence: 99%

“…Forensic pathologists, emergency medicine physicians, and first responders still see people with this clinical presentation, regardless of the change in terminology. 3,23,41,70 There are countless instances (many on video) of such hyperactive activity as people stripping off their clothing, walking naked down the middle of a street, often shouting incoherent utterances, hurting themselves, threatening or otherwise menacing others, destroying property, and/or not cogently responding to verbal interactions. These people are suffering from an acute hyperactive delirium.…”

Section: Who Makes the Diagnosis?mentioning

confidence: 99%

“…Acute hyperactive delirium is potentially fatal 2,3,7,18,20–48 . What was once called a cocaine-induced excited delirium is medically a cocaine-induced acute hyperactive delirium .…”

Section: Not a Medical Diagnosismentioning

confidence: 99%

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