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Emergency Medicine News:
doi: 10.1097/01.EEM.0000405486.70675.c9
Breaking News

Breaking News: Task Force Defines, Recommends Treatment for ExDS

Scheck, Anne

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It was brief — only a few lines of text — but the plea for more research on Excited Delirium Syndrome (ExDS) obviously was written by a grieving family member, and that's probably why it made headlines in a British newspaper this past summer.

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“We fully recognize that drug toxicity played a key role in Jason's death,” wrote the deceased's uncle after a coroner's report attributed the fatality to cardiac arrest in police custody. So, he asked, shouldn't his nephew's lost life put more focus on the “potential of this condition” to help prevent future tragedies? (http://bit.ly/pOuTGZ.)

Prehospital and emergency medical care is essential to saving lives from ExDS, and “many cases of fatality probably could be prevented with treatment,” said Mark DeBard, MD, an emergency physician who served on the task force instrumental in ExDS' acceptance as a distinct syndrome two years ago from the American College of Emergency Physicians. (EMN 2009;31[11]:4; http://bit.ly/ory9ec.)

Following that acceptance, the task force worked to define the condition, looking at its epidemiology, pathophysiology, and clinical characteristics. That consensus paper, to be published in an upcoming issue the Journal of Emergency Medicine, concludes that ExDs has uncertain but multiple etiologies, but is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction. The group, led by Gary Vilke, MD, and Dr. DeBard, said the risk of death is likely increased with physiologic stress, and called for immediate sedation to reduce the chance of death.

Research so far has shown that most of those who die are noncompliant and exhibit severe aggression. (Am J Forensic Med Pathol 2009;30[1]:23.) And a stressful encounter increases the chemical imbalance in the brain that is characteristic of ExDS. The hyper-responsive neuroendocrine system aggravates an already acidotic state, which can progress rapidly and fatally, explained Dr. DeBard, a clinical professor of emergency medicine at Ohio State University in Columbus.

Because certain drug use and physical resistance to intervention are signs of ExDS, restraint by TASER is more frequently used by law enforcement. But this year, after ExDS was pronounced the cause of death for a Connecticut man following a reported 34 stuns by police, lawmakers there drafted a bill that will mandate a study on the use of such electronic jolts (SB 6615), in part to answer the question: Does the way these devices are employed affect outcome? (The Hartford Courant May 3, 2011; http://bit.ly/mPSjqa.)

Previous studies have, in fact, found that less injury occurs among police departments with policies that place TASER use alongside deadly force. (Law & Order 2008;56[3]:93.)

Only a few years ago, “positional asphyxiation” was the claim often made when suspected criminals died after being placed in restraints. “We refuted that,” said Gary Vilke, MD, a professor of clinical medicine at the University of California, San Diego, and the director of clinical research in emergency medicine at UCSD Medical Center. In fact, the circumstances of such arrests often included hallmarks of ExDS — profuse sweating, high body temperature, delusional behavior — but such symptoms were not taken into account until the syndrome was actually studied.

“We asked: ‘Well, if that is not what is killing them, what is?’ The answer, said Dr. Vilke, turned out to be a delirium first described in psychiatric patients around the late 1800s, but which all but disappeared from medical journals by the 1950s following the utilization of antipsychotic medication. Thirty years later, it was rediscovered in individuals using cocaine, among other stimulants.

Police departments that learn to recognize the signs, that have a protocol in place for managing it, and that institute a training program for officers are helping to reduce risk, said Dr. DeBard, adding: “I'm concerned that it [diagnosis of ExDS] be used appropriately.” In a metropolitan city of a million people, there probably should be only one to three cases of ExDS annually, he said. “There needs to be an understanding of the difference between bad behavior, drunken behavior, and excited delirium,” Dr. DeBard said.

An increase in deaths linked to ExDS following TASER use seems to be raising questions about such fatalities, particularly with the American Civil Liberties Union. A few months ago, the ACLU published an investigative survey on TASER use by 20 Arizona law enforcement agencies. One conclusion: Though dispensing an electrical charge is largely regarded as an alternative to lethal force, it may be applied in situations in which compliance can be achieved in other ways.

And, in an opinion similarly expressed by Dr. DeBard, the ACLU called on law enforcement agencies to “make sure that officers have enough training and preparation to deal with intoxicated or emotionally disturbed individuals, so that they are able to de-escalate a situation without resorting to force.” (A Force To Be Reckoned With, ACLU of Arizona, 2011; http://bit.ly/n51pjt.)

A previous ACLU examination of the issue, which looked at cases in California, found that deaths in custody had increased along with the utilization of allegedly nonlethal electronic weaponry. (Stun Gun Fallacy: How the Lack of TASER Regulation Endangers Lives, ACLU of Northern California, 2005; http://bit.ly/q9rIhl.) The idea that there is physical risk imposed by TASER use isn't the sole source of the debate; one suggestion is that it might contribute to ExDS death.

But is there more risk from the TASER than from the syndrome itself? Not likely, said Michael Wilson, PhD, MD, a clinical research fellow of emergency medicine at UCSD. The very act of resisting custody exacerbates the life-threatening cardiac stress, he explained. “These are people who might walk — even run — right into traffic,” he said.

“It is important to note that some people, even those who haven't been TASERed, die unexpectedly while in custody,” said David Murphy, PhD, an associate professor of criminal justice at Western Oregon University, who has studied restraint alternatives and consulted on them with police. “TASER use is by no means the only type of law enforcement response with the potential to cause or exacerbate symptoms of excited delirium,” he said.

Cuffing the individual with hands behind the back or forcing a suspect to the ground could also be dangerous. So could any force used to achieve compliance in a person at risk for death due to ExDS, he said.

There is reason to believe TASER use saves lives. About the same time as the ACLU published its results, the U.S. Department of Justice issued its own research findings on the issue, noting that the injury rates in two cities — Orlando, FL, and Austin, TX — had dropped substantially for suspects and police officers after the devices were adopted.

In a white paper published by the ACEP task force, the association between cocaine use and ExDS is emphasized, and so is the threat of dying at levels similar to recreational use. So what is the “different mechanism of death” alluded to in the ACEP paper? And can that mechanism be adversely influenced by TASER?

Data from the U.S. Justice Department — the same data that found lower injury rates with TASER use — also indicate that when TASER injuries do occur, the application sometimes had been repetitive, and carried out in ways such as pressing against flesh rather than release of a dart from a distance. (Police Use of Force, TASERs and Other Lethal Weapons, Research in Brief by the National Institute of Justice, 2011; http://1.usa.gov/o1pq5E.)

TASER has an exceptional profile of safety, said Steve Tuttle, the vice president of communications for TASER International, Inc., in Scottsdale, AZ. News accounts about these electronic-control devices often fail to distinguish between the two ways in which they can be used: discharging an electrical stun directly in contact with a subject, an approach that causes pain but is unlikely to cause incapacitation, or by deploying probes that confer a low-level current that usually subdues the subject.

Adding to the potential for confusion, discussions of “firings” can be too general. “The number of deployments does not necessarily reflect the number of probes that have reached the intended target or the number of stuns. Even when the firings are successful, the electrical impact can be reduced or avoided by clothing,” Mr. Tuttle said.

Unfortunately, there is no clear way to differentiate between individuals prone to quick progression to death and those who show a fairly immediate response to treatment. “We don't really have an answer as to why some end up on the medical examiner's table,'' Dr. Vilke said.

This much is clear: When ExDS is seen in the emergency department, the majority of patients are treatable, Dr. Vilke pointed out, with mortality estimated to be eight to 11 percent. Other statistics are less certain. Incident reports generally are anecdotal, and prevalence remains unknown, he observed. “There are just no numbers on that.”

Comments about this article? Write to EMN at emn@lww.com.

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© 2011 Lippincott Williams & Wilkins, Inc.

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