Medical conditions and restraint in patients experiencing excited delirium

Law enforcement restraint-related death is frequently associated with excited delirium syndrome (ExDS). Because such deaths are rare, the pathophysiology underlying ExDS deaths remains unknown, making identification of high-risk situations challenging. This study describes the medical conditions and situations surrounding restraint of individuals identified by law enforcement to be experiencing ExDS.

Individuals with ExDS as determined by law enforcement officers during use of force encounters over a 3-year period were identified. For subjects who were brought to the emergency department after restraint, medical records and police narratives were reviewed to identify circumstances surrounding restraint, abnormalities found during evaluation, and final diagnoses.

Sixty-six cases were identified, of which 43 had emergency department evaluation. On presentation, 36 (84%) were tachycardic and 3 (7%) were hyperthermic; 35 (77%) had toxicology studies positive for stimulants; 2 (5%) had a pH level less than 7.2, and 5 (12%) had an elevated lactate; and 3 (7%) had a creatinine kinase level higher than 1500 U/L. Two (5%) patients were admitted to the hospital for medical reasons: one had had a field pulseless electrical activity arrest prior to restraint and the other was admitted for rhabdomyolysis.

Officer-identified cases of ExDS infrequently involved individuals requiring extensive restraint or with medical conditions that objectively placed them at high risk for sudden death. The low specificity of this syndrome in predicting risk of sudden death may present a challenge to law enforcement and emergency physicians.