10. EXCITED DELIRIUM                                  
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Definition                                  
Excited delirium is defined as “a state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, √ √   √ √ √ √ √     √   √ √ √ √ √
exceptional strength and endurance without apparent fatigue” (Morrison and Sadler, 2001). (TI v.11, v.13, v.14)
Excited delirium is a symptom of an underlying condition; it is not a stand-alone diagnosis. (TI v.11)               √                  
Excited delirium occurring as a precursor to sudden in-custody death is not a new phenomenon. (TI v.11)             √ √                  
Many conditions requiring immediate medical treatment may result in a state of excited delirium; sudden and unexpected death proximal to restraint is not a       √           √           √  
rare occurrence; there are approximately 200 deaths every year following police restraint.
Training information on excited delirium is obtained from CPRC research, BCOPCC Final Report, research led by Dr. Christine Hall, MD, and the collective       √           √           √  
excited delirium articles and papers from Chris Lawrence, MA, (OPC).
Causes                                  
Causes of excited delirium: psychiatric illness; stimulant abuse; may be a combination of both; alcohol withdrawal; insulin shock/very low blood sugar; head injury; other medical problems.       √           √           √  
Death following excited delirium state: medical experts investigating reasons for death—no clear single cause currently known; multi-factorial; usually occurs following struggle and restraint; research is continuous and ongoing.       √           √           √  
Physiology                                  
Excited delirium may involve an organic chemical imbalance in the brain,
psychiatric illness, or stimulant abuse. Excited delirium can be caused by hypoxia, 		              √         √        
hypoglycemia, stroke and intra-cranial bleeding. Excited delirium involves sympathetic nervous system arousal, and is a runaway of the flight-or-fight
response (primitive survival response). Excited delirium is associated with an increase in adrenaline/noradrenaline release, an increase in body temperature
(hyperthermia), an increase in serum CO2, decrease in blood pH, exertional rhabdomyolysis (lactic acid), heart arrhythmia, and cardiac arrest. (TI v.11)
Sympathetic nervous system arousal; huge increase in adrenaline; an uncontrolled escalation of violent/evasive behaviour—“fight-or-flight” primitive survival response;       √           √           √  
increase in body temperature (hyperthermia). The body is managing a series of complex metabolic events at once; the ability to manage decreases over time.
Subject may be on the verge of physiologic collapse; limiting the duration of the struggle and expediting medical care may help prevent death.
We do not know what EXACT physiological factors can lead to death in one circumstance but not in another; we do not know how to predict who will die       √           √           √  
when or why; you cannot tell who will die by the duration/intensity of the struggle or by the response option used.
Subject exhibits                                  
Bizarre or violent behaviour. (TI v.11, v.12, v.13, v.14) √ √ √ √ √ √ √ √   √ √   √ √ √ √ √
Bizarre, purposeless, and/or aggressive behaviour.       √           √           √  
Violent and/or evasive behaviour (typical).       √           √           √  
Paranoia. (TI v.11)       √       √   √           √  
Panic. (TI v.11)               √                  
Signs of overheating/disrobing. (TI v.11, v.12, v.13, v.14) √ √ √ √ √ √ √ √   √ √   √ √ √ √ √
Slurring or slowness of speech. (TI v.11)     √       √ √         √        
Primitive sounds/unintelligible speech.       √           √           √  
Imperviousness to pain/self-mutilation. (TI v.11, v.12, v.13, v.14) √ √ √ √ √ √ √ √   √ √   √ √ √ √ √
Disturbances in breathing patterns or loss of consciousness. (TI v.12, v.13, v.14) √ √ √   √ √         √   √ √ √   √
Violence toward/attacking glass, lights, and reflective surfaces. (TI v.11, v.13, v.14) √ √     √ √ √ √     √   √ √ √   √
Breaking glass and/or banging on inanimate objects.       √           √           √  
Superhuman strength and endurance. (TI v.11, v.13, v.14) √ √   √ √ √ √ √   √ √   √ √ √ √ √
Complaints of respiratory difficulty. (TI v.14) √ √     √ √                 √    
Lid lift (eyes opening so wide the whites of the eyes are completely visible). (TI v.11)       √     √ √   √     √     √  
Uncontrolled shaking. (TI v.11)             √ √         √        
Disorientation.       √           √           √  
Hallucination.       √           √           √  
Vigorous resistance. (TI v.11)       √     √ √   √     √     √  
Flight behaviour. (TI v.11)       √     √ √   √     √     √  
Irrational physical behaviour. (TI v.11)       √     √ √   √     √     √  
Hyperactivity.       √           √           √  
Subject does not respond to verbal direction; ignores police presence.       √     √     √     √     √  
Walking and/or running in traffic.       √           √           √  
Subject exhibits sudden tranquility; first symptom of death may be tranquility or ragged breathing.       √           √           √  
Can occur at any time during or after restraint.       √           √           √  
Cannot be predicted based on subject behaviour.       √           √           √  
Occurs in police cars, cells, ambulances, and hospitals; majority die at the scene.       √           √           √  
Protocol in dealing with excited delirium                                  
Should one or more of the behaviours manifest, the suspect may require immediate medical assistance due to pre-existing conditions, possible overdose, cocaine √ √ √   √ √ √       √   √ √ √   √
psychosis, excited delirium, etc. Consider having EMS standing by. (TI v.12, v.13, v.14)
When taking a call regarding a possible excited delirium subject, the call-taker should ask the following questions: known history of schizophrenia; mania/bipolar       √           √           √  
illness; substance abuse; known medical conditions; previous similar incident(s) of an acute agitated state.
This is a medical problem which manifests itself in such a manner that the police are typically the first responders. (TI v.11)               √                  
Realize that subjects presenting these signs are in a medical emergency.       √           √           √  
The subject must be controlled before they can be treated.       √           √           √  
Instruct your officers to watch for these danger signs.  If a suspect exhibits any of these signs, get them to medical attention as quickly as possible, as these people √ √ √   √ √         √     √ √   √
are at elevated risk for in-custody death. (TI v.12, v.13, v.14)
Especially when dealing with persons in a health crisis such as excited delirium, it is advisable to minimize the physical and psychological stress to the subject to the greatest degree possible. (TI v.12, v.13, v.14) √ √ √ √ √ √       √ √     √ √ √ √
There can be no medical treatment without restraint. (TI v.11)       √     √ √   √     √     √  
Weigh the need for immediate control against the risk to the subject. (TI v.11)       √       √   √     √     √  
Pre-contact strategies when dealing with those in an excited delirium state:
● Keep your distance.
● If possible, lower the lights.
● Slow your speech and lower your voice.
● Slow your physical movements.
● Keep your hands visible.
● Create distance slowly.		             √           √        
Pre-contact strategies when dealing with those in an excited delirium state:       √           √           √  
● Keep your distance until contact and/or restraint becomes necessary.
● Simple and clear commands; understand the subject may not respond.
● If tactically feasible, maintain a safe time/distance ratio.
For effective public and police safety do not: lower the lights, as there is no information to suggest this will alter the excited delirium state; “slow your physical       √           √           √  
movements”—there is no evidence to support that this will alter an ED state.
Keep those experiencing excited delirium talking if possible (to cause cognitive pattern interruption). (TI v.11)             √ √         √        
Physical Intervention Strategies
Assess the situation and if excited delirium is suspected:		             √           √        
● Contact EMS and have them attend (be sure to mention excited delirium as this will bump up their call response).
● If reasonable, have a supervisor on scene.
● If reasonable, have the EMH team attend.
● Have a plan for physical intervention, if required.
● Once the subject is restrained, turn them over to EMS immediately.
Response strategies for dealing with those in an excited delirium state:         √           √           √  
● Develop a response strategy prior to deployment of intervention if possible and include EHS (highest level possible) attendance in your strategy.
● A coordinated strategy to restrain the subject should include those options that expedite control and subsequent medical treatment.
● Prolonged struggle represents increased risks.
The CEW in probe deployment mode may be the most effective response to establish control.       √           √           √  
A single CEW deployment made before the subject has been exhausted, followed by an effective restraint technique may provide the optimum outcome.       √           √           √  
Persons experiencing excited delirium have a high tolerance for pain so the operational use of a drive-stun may be more of an annoyance than a compliance-                         √        
gaining tool, and could escalate the level of resistance.
Response strategies: EHS to attend with members; ensure enough members on scene for quick and effective control; consider use of CEW in probe mode for       √           √           √  
immediate incapacitation to establish control; sufficient members to control arms and legs; handcuff to rear.
Remove the subject from prone position as soon as possible after control is established; if EHS is not at scene and the subject suddenly becomes quiet and       √           √           √  
stops resisting, advanced life support should be summoned where available, and preparation for CPR should be made; subject to be placed in EHS care as soon
as possible for transport to Health Services.
Remember, the maximal prone position may compromise the subjects ability to adequately ventilate following a violent struggle. Therefore, as soon as is possible,                         √        
place the subject in a supine (partially seated) position. If this is not practicable, at the very least, place the subject on their left side if possible.
Remove the subject from the prone position as soon as possible after control is established:               √         √        
● Inform EMS of circumstances.
● Do not allow EMS to transport in the maximal prone position.
● Go with EMS and brief ER staff. (TI v.11)
Your observations are critical for ER staff to understand what has occurred and treat it accordingly. Your observation and notes cannot adequately be relayed to ER       √           √     √     √  
staff by EMS personnel in a timely manner. Therefore, it is important that one officer goes with the ambulance.
If there is evidence of chemical/stimulant use, seize as an exhibit as per policy.       √           √           √  
If there is any evidence of chemical or stimulant use, obtain a sample if there is any left and turn it over to the ER staff.                         √        
If possible, have a supervisor on the scene. (TI v.11)             √ √         √        
Engage in post-incident care of involved officers. (TI v.11)               √                  
ABCs should be monitored continually once the subject is under control.       √           √           √  
Documentation                                  
Document the incident. (TI v.11)               √                  
All investigation should be turned over to uninvolved members as soon as possible. (TI v.11)               √                  
Identify witnesses. (TI v.11)               √                  
Obtain core temperature as soon as possible. (TI v.11)               √                  
Discuss with coroner as soon as possible the concept of brain examination. (TI v.11)               √                  
Document any damage caused by the subject. (TI v.11)               √                  
Collect evidence, in particular, any intermediate weapon deployed. (TI v.11)               √                  
Member training regarding excited delirium                                  
Training materials submitted include excited delirium bibliographic/research supplementary materials. (TI v.11)               √         √        
Training materials submitted address excited delirium. (TI v.12, v.13, v.14) √ √ √ √ √ √ √     √ √   √ √ √ √ √
Training materials submitted do not address excited delirium.                 √                
Excited delirium training is a separate training course.                       √ √        
“Excited Delirium and Its Correlation to Sudden and Unexpected Death Proximal to Restraint: A Review of the Current and Relevant Medical Literature” by                         √        
A/Insp. Darren Laur; Victoria Police Department, April 2005. The information contained in this paper should be shared with all first responders and medical
care workers who may come into contact with those experiencing excited delirium. If your agency has experienced a sudden and unexpected death proximal to
restraint, this paper should also be shared with investigators, coroners, medical examiners, pathologists, and lawyers, or anyone else who is involved in the investigation of the death.
Modified restraint information                                  
Training materials contain information about modified restraint tactics and techniques.       √           √     √     √  
Officers no longer engage in “hog tie” restraint.       √           √           √  
Officers are trained in waist and leg restraint techniques.       √           √     √     √