Excited Delirium – An unsatisfactory diagnosis

“Excited Delirium” (ED) is a medical condition more likely to be diagnosed by law enforcement agencies than by medical personnel.

It is a title accepted by many forensic pathologists, becoming the most common diagnosis on the death certificates of individuals dying in custody after being Tasered. In spite of this, it has yet to be an accepted diagnosis for psychiatrists, and remains controversial in medical circles. Nevertheless a professional association of Emergency Physicians in the United States has thrown its support behind the diagnosis. It is these physicians who are most likely to encounter the condition, on referral from police.

Why is the diagnosis of Excited Delirium controversial?

A diagnosis should take into account factors such as:

  • The underlying pathological process such as inflammation, cancerous proliferation, or injury.
  • The specific anatomical site
  • The probable aetiological agent or condition such as a particular infecting organism, or a chromosomal abnormality..
  • A particular body state, such as obesity, hypertension or coma.
  • An organ or system failure

 Excited delirium is a descriptive name not fulfilling such criteria

It has two aspects not specific to any one medical complaint.

  1. Delirium is a non-specific clinical feature of many illness including febrile states, psychiatric ailments and drug and alcohol induced intoxication. Consciousness is clouded; there may be involuntary movements, hallucinations, incoherent speech, and pyrexia with profuse sweating and rapid pulse.
  2. The word “excited” adds a connotation of agitation, hyperactivity, aggression, increased strength and increased pain tolerance, to the clinical picture.

 

In the same way that terminal uraemic coma supervenes in renal failure, Excited Delirium can evolve from a less serious state of a drug or chemical intoxication, or extreme hyperactivity in manic psychiatric illnesses. Attempts to restrain patients physically, or with capsicum spray and Tasers are likely to be counter-productive and to precipitate such a transition.

A diagnosis of Excited Delirium is often made by a process of exclusion of other causes at autopsy. The absence of any structural pathology suggests that death is due to fatal physiological changes such as extreme tachycardia (rapid heart rate) leading to circulatory failure, respiratory compromise, and a dangerously high body temperature. These finding suggest excessive stimulation, and hyperactivity of, the autonomic nervous system. Such changes are no longer apparent after death on autopsy examination.

In 2008 the Minister of Justice for Novo Scotia, Cecil P. Clarke, appointed an expert panel to review the use of conducted energy devices (CED) by law enforcement agencies.

http://gov.ns.ca/just/public_safety/_docs/Excited%20Delirium%20Report.pdf

This enquiry was detailed, the recommendations well-considered, and relevant to our Australian experiences. It merits detailed study in its entirety, but this post focuses on the use of the term “Excited Delirium”, a term better replaced by “Autonomic Hyper-arousal State” (AHS), as suggested by the expert panel.



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