Excited delirium syndrome (ExDS) is defined by the key clinical features of marked agitation, psychotic behaviour, violent behaviour with 'extraordinary strength', and hyperthermia. It is frequently associated with police intervention and the use of 'extreme force' in restraint/arrest scenarios. Today there is a strong association with stimulant drugs of abuse use, and infrequently with acute psychiatric psychotic episodes. Similar features have been described since 1847, primarily in the setting of psychiatric psychotic episodes in lunatic asylums, up until there was effective anti-psychotic drug therapy in the 1950 s. There are also similarities to the malignant neuroleptic syndrome.
There is a significant risk (~10%) of sudden death, which in the death-in-custody scenario is often highly controversial due to the restraint methods employed. When sudden death occurs, it is typically immediately post-struggle, and shows a bradycadia-asystole ECG pattern. There is a high incidence of stimulant drugs (especially cocaine) in the toxicology. Autopsy findings generally fail to show a satisfactory cause of death.
The presentation will outline the features of ExDS, the history, the theories proposed to explain deaths in ExDS, an approach to autopsy in these deaths, and a discussion of how to sign out these cases.
(C) 2013 Royal College of Pathologists of Australasia