On March 23, 2023, the American Society of Medical Examiners released a position statement to its members, recommending that “excited delirium” no longer be listed as an official cause of death, joining the American Medical Association and the American Psychiatric Association in refusing to recognize the phenomenon as an official medical or psychiatric diagnosis.
So what does this mean to EMS providers?
Nothing, really. If you’re using “excited delirium” in your documentation; stop. Otherwise, treat the patient appropriately and document thoroughly. You don’t need specific nomenclature to describe a patient with extreme physiologic arousal, altered mental status or possible drug intoxication, just like you don’t need to classify bullet holes as entrance or exit wounds in your documentation.
All it does is muddy the waters.
In practical terms, “excited delirium” is a very generic term used to describe a constellation of symptoms, among them heightened sympathetic nervous system response, altered mental status, acidosis, diaphoresis and hyperthermia. It’s like saying, “The patient died from cardiac arrest.”
Well, duh. Every patient dies of cardiac arrest.
Some of these patients die whether they are restrained or not. In the unrestrained, it may be due to arrhythmia, myocardial infarction or stroke. In the prone restrained patient, it’s likely going to be respiratory failure and acidosis from restraint asphyxia. Interference with metabolism of dopamine, serotonin and acetylcholine also contribute to the mania and hyperthermia these patients often exhibit. In extreme cases of prolonged physical restraint, rhabdomyolysis and disseminated intravascular coagulopathy have occurred.
Providers need to be aware of the extreme physiologic changes present in these patients, and work expeditiously to “stop the fight.” That fight may be patient versus restraints, or patient versus providers, and even patient versus their own physiologic and metabolic limits.
Position your patient in semi-Fowler’s position, restrain the limbs if need be, and administer an appropriate dose of sedative to blunt the catecholamine dump that usually accompanies such phenomena. Remember that physical restraint is only half the solution; relying solely on physical restraint merely shifts the fight from patient versus paramedics to patient versus restraints.
Shunning terms like “excited delirium” means we focus more on the proximate cause of the death, which may be restraint asphyxia, sudden cardiac arrest from arrhythmia, a stroke or any number of things. It’s a means for the medical community to recognize that in-custody deaths are usually not from that constellation of symptoms; they’re due to the EMS and law enforcement response to that constellation of symptoms.
That’s a hard sell to our law enforcement brethren, many of whom believe in excited delirium just as fervently as they do occupational exposure to fentanyl. Police officers will tell you that restraint asphyxia does not exist, and they have scientific studies to back it up. There are multiple studies that show no impairment of respiratory mechanics or cardiovascular parameters when 25-50 pounds of weight is applied between the shoulders of a prone, healthy and cooperative volunteer subject.
Prone, healthy and cooperative volunteer subjects.
Police don’t arrest and EMS doesn’t restrain cooperative people. The people we encounter struggle, may be under the influence of stimulant drugs and they’re quite often unhealthy. That stew of physical exertion, hypertension, tachycardia and metabolic acidosis makes them a different case entirely than the healthy study subjects. We need to maximize respiratory compensation in our restrained patients – physiologically normal isn’t good enough.
The next time you encounter a patient for which your clinical impression is “excited delirium,” remember that the treatment you render isn’t to treat the delirium, it’s to treat the physiologic derangements that result, no matter what people call it.
