HM Medical Clinic


Excited delirium checklist for chief's

Excited Delirium Checklist
Excited delirium or excited delirium syndrome is only one form of potential sudden death that law enforcement officers may encounter. Other potential causes of unexpected arrest-related deaths include, but are not limited to: SUDEP1,2 (sudden unexpected death in epilepsy), sickle cell sudden death,3 various cardiomyopathies,4 drug induced arrhythmias (including those caused by alcohol5,6 and marijuana7-10), psychiatric arrhythmias (whether due to schizophrenia11 or medications12), and severe coronary artery disease. Present?
911 Call – Emergency Contact for Assistance
1. Critical call phrases include, "He just freaked out," "just snapped," "flipped out," or a person is "running around naked."13 Law Enforcement
2. Agitation, screaming, extreme fear response or panic14-18 3. Violence, assault, or aggression towards others18-21 4. Suspicion of impending death. Typical comments include, "I'm dying," "Please save me," or "Don't kill me"22 5. Incoherence or disorganized speech. Grunting or animal sounds21,23 6. Clothing removal inappropriate for ambient temperature or complete 7. Disorientation or hallucinations18,27-30 8. Mania, paranoia, anxiety, or avoidance behavior14,18,31-34 9. Constant motion or hyperactivity14,30,35-37 Capture, Control and Restraint of Subject
10. Extreme or "super human" strength21,33 11. High threshold of or imperviousness to pain23,26 12. Extreme stamina38,23 13. Brief quiet period before collapse likely corresponding with respiratory arrest14,17,23,39 Emergency Medical Services Contact and Intervention
14. Presenting rhythm of PEA (pulseless electrical activity) or asystole.38,40-42 Also documented by "No shock advised" with automatic external defibrillator42 Emergency Department
15. High core body temperature.15,16,21,31,43,44 16. Acidosis (acidic blood)23,45,46 17. Rhabdomyolysis (if suspect is resuscitated).15,44,47 Law Enforcement/Forensic Investigator Death Investigation
18. History of chronic stimulant abuse or mental illness14,19,27,32,37,40,48-51 History of violence or drug related arrests, mental health histories and treatments, and drug rehabilitation interventions, etc. 19. Damage to shiny objects such as glass, mirrors and lights.23 Reported behaviors may include attacking a squad car light bar or charging oncoming traffic at night. Occasionally generalized vandalism. Pathologist – Medical Examiner Investigation
20. Minor injuries from fighting against restraints (e.g. handcuffs, hobbles). 21. Positive Mash (central nervous system biomarkers) test for dopamine transporter assay and heat shock protein.15,31,32,52-56 22. Positive brain and hair toxicology screen for chronic stimulant abuse.52,57- 61 Post-incident drug levels may be low to negative. Contributors: Mark Kroll, PhD; Charles Wetli, MD; Deborah Mash, PhD; Steven Karch, MD; Michael Graham, MD, Jeffrey Ho, MD. A syndrome is an aggregate of signs and symptoms that define a medical condition. Not all persons with a certain syndrome have all the same signs and symptoms. Not all cases of a syndrome result from the same cause. For example, some persons with carpal tunnel syndrome will have numbness and tingling, while others will have weakness and pain. Also, some persons with carpal tunnel syndrome will have it because of trauma, while others will have the syndrome because of pregnancy, diabetes, rheumatoid arthritis or thyroid disease. Persons with the excited delirium syndrome will have various combinations of some of the signs and symptoms listed above. The cause (etiology) of the excited delirium syndrome in any individual may be due to one or more of a number of conditions. The most common conditions are mental illness and illegal stimulant abuse (especially cocaine and methamphetamine).40 Because the term "excited delirium syndrome" has not been widely used until recent years, many physicians do not recognize the term even though they may be very familiar with agitation and deaths due to drugs and other conditions. It is important to avoid the distraction of the various terms that have been applied to this syndrome. For example, what is now referred to as excited delirium14-16,26,32,33,36,38-40,44-47,50,53,54,62-69 or agitated delirium41,56,70-115 has also been called: Bell's mania,30 acute exhaustive mania,116 acute delirious mania,30 delirium grave,30 typhoma,30 acute delirium,30 manic-depressive exhaustion,24 excited catatonia,89 lethal catatonia,117 and neuroleptic malignant syndrome.19,26,43,72,117 Statistical Confidence:
There must be at least 5 positive criteria to diagnose excite delirium syndrome. For 12 or more positive criteria the confidence level is at least 99.9%. For less than 12 positive criteria the confidence depends on the number of criteria for which information is available. For example, the brain and hair tests are, unfortunately, typically not done. Often the blood tests for rhabdomyolysis is not done. In this case there will only be information on 19 criteria. If 8 of these 19 criteria were positive then the confidence in the diagnosis would be 93%. Number of Positive Criteria Number of Criteria With Information References:
1. So EL. What is known about the mechanisms underlying SUDEP? Epilepsia
2008;49 Suppl 9:93-8.
2. So NK, Sperling MR. Ictal asystole and SUDEP. Neurology 2007;69:423-4.
3. Channa Perera SD, Pollanen MS. Sudden death due to sickle cell crisis
during law enforcement restraint. J Forensic Leg Med 2007;14:297-300.
4. Yeo KK, Wijetunga M, Ito H, Efird JT, Tay K, Seto TB, Alimineti K, Kimata C,
Schatz IJ. The association of methamphetamine use and cardiomyopathy in
young patients. Am J Med 2007;120:165-71.
5. Rosenqvist M. Alcohol and cardiac arrhythmias. Alcohol Clin Exp Res
6. Kupari M, Koskinen P. Alcohol, cardiac arrhythmias and sudden death.
Novartis Found Symp 1998;216:68-79; discussion 79-85.
7. Baranchuk A, Johri AM, Simpson CS, Methot M, Redfearn DP. Ventricular
fibrillation triggered by marijuana use in a patient with ischemic
cardiomyopathy: a case report. Cases J 2008;1:373.
8. Aryana A, Williams MA. Marijuana as a trigger of cardiovascular events:
speculation or scientific certainty? Int J Cardiol 2007;118:141-4.
9. Rezkalla SH, Sharma P, Kloner RA. Coronary no-flow and ventricular
tachycardia associated with habitual marijuana use. Ann Emerg Med
10. Akins D, Awdeh MR. Marijuana and second-degree AV block. South Med J
11. Bar KJ, Koschke M, Boettger MK, Berger S, Kabisch A, Sauer H, Voss A,
Yeragani VK. Acute psychosis leads to increased QT variability in patients
suffering from schizophrenia. Schizophr Res 2007;95:115-23.
12. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic
drugs and the risk of sudden cardiac death. N Engl J Med 2009;360:225-35.
13. Code 1069 Excited Delirium Dispatch Policy. In: Sheriff's_Office, ed.
Jacksonville, FL, 2006.
14. Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death
related to restraint for excited delirium: a retrospective study of deaths in police
custody and in the community. CMAJ 1998;158:1603-7.
15. Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC.
Fatal excited delirium following cocaine use: epidemiologic findings provide
new evidence for mechanisms of cocaine toxicity. J Forensic Sci 1997;42:25-
16. Blaho K, Winbery S, Park L, Logan B, Karch SB, Barker LA. Cocaine
metabolism in hyperthermic patients with excited delirium. J Clin Forensic Med
17. Stefan H. Sudden death of psychiatric patients following great excitation
and exhaustion which has no actual anatomic basis. Dtsch Med Wehnschr
18. Shulack N. Sudden "exhaustive" death in excited patients. Psychiatr Q
19. Kasantikul D, Kanchanatawan B. Neuroleptic malignant syndrome: a
review and report of six cases. J Med Assoc Thai 2006;89:2155-60.
20. Bell L. On a form of disease resembling some advanced stages of mania
and fever, but so contradistinguished from any ordinary observed or described
combination of symptoms as to render it probable that it may be overlooked
and hitherto unrecorded malady. American Journal of Insanity 1849;6:97-
21. Fishbain DA, Wetli CV. Cocaine intoxication, delirium, and death in a body
packer. Ann Emerg Med 1981;10:531-2.
22. Karch S, Kroll M. Unpublished observations of 150 excited delirium cases,
23. Wetli C. Excited delirium. In: Chan R, ed. Sudden Deaths in Custody.
Totawa: Humana Press, 2006:99-112.
24. Derby I. Manic-depressive "exhaustion" deaths. Pyschiatric Q 1933;7:436-
25. Shulack N. Sudden "exhaustive" death in excited patients. Psychiatr Q
26. Ross DL. Factors associated with excited delirium deaths in police
custody. Mod Pathol 1998;11:1127-37.
27. Stagno D, Gibson C, Breitbart W. The delirium subtypes: a review of
prevalence, phenomenology, pathophysiology, and treatment response. Palliat
Support Care
28. Ross CA, Peyser CE, Shapiro I, Folstein MF. Delirium: phenomenologic
and etiologic subtypes. Int Psychogeriatr 1991;3:135-47.
29. Davidson G. Concerning the cause of death in certain cases. Am J
30. Kraines S. Bell's mania (acute delirium). Am J Psychiatr 1934;91:29-40.
31. Mash DC, Ouyang Q, Pablo J, Basile M, Izenwasser S, Lieberman A,
Perrin RJ. Cocaine abusers have an overexpression of alpha-synuclein in
dopamine neurons. J Neurosci 2003;23:2564-71.
32. Mash DC, Pablo J, Ouyang Q, Hearn WL, Izenwasser S. Dopamine
transport function is elevated in cocaine users. J Neurochem 2002;81:292-
33. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in
recreational cocaine users. J Forensic Sci 1985;30:873-80.
34. Anglin MD, Burke C, Perrochet B, Stamper E, Dawud-Noursi S. History of
the methamphetamine problem. J Psychoactive Drugs 2000;32:137-41.
35. Schroeder U, Schroeder H, Darius J, Grecksch G, Sabel BA. Simulation of
psychosis by continuous delivery of phencyclidine from controlled-release
polymer implants. Behav Brain Res 1998;97:59-68.
36. Pedal I, Zimmer G, Mattern R, Mittmeyer HJ, Oehmichen M. [Fatal
incidences during arrest of highly agitated persons]. Arch Kriminol 1999;203:1-
37. Fava M. Psychopharmacologic treatment of pathologic aggression.
Psychiatr Clin North Am 1997;20:427-51.
38. DiMaio T, VJM D. Excited delirium syndrome cause of death and
prevention. Boca Raton: Taylor & Francis, 2006.
39. Stratton SJ, Rogers C, Green K. Sudden death in individuals in hobble
restraints during paramedic transport. Ann Emerg Med 1995;25:710-2.
40. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with
sudden death of individuals requiring restraint for excited delirium. Am J
Emerg Med
41. Park KS, Korn CS, Henderson SO. Agitated delirium and sudden death:
two case reports. Prehosp Emerg Care 2001;5:214-6.
42. Swerdlow C, Kroll M, Williams H, Biria M, Lakkireddy D, Tchou P.
Presenting Rhythm in Sudden Custodial Deaths After Use of TASER®
Electronic Control Device. Heart Rhythm 2008;5:S44.
43. Nielsen J, Bruhn AM. Atypical neuroleptic malignant syndrome caused by
olanzapine. Acta Psychiatr Scand 2005;112:238-40; discussion 240.
44. Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis
and excited delirium: different stages of the same syndrome. Am J Forensic
Med Pathol
45. Allam S, Noble JS. Cocaine-excited delirium and severe acidosis.
Anaesthesia 2001;56:385-6.
46. Brice JH, Pirrallo RG, Racht E, Zachariah BS, Krohmer J. Management of
the violent patient. Prehosp Emerg Care 2003;7:48-55.
47. Karch SB. Karch's Pathology of Drug Abuse 2002:541.
48. DiMaio VJ. Forensic Pathology 2001:656.
49. Gray SD, Fatovich DM, McCoubrie DL, Daly FF. Amphetamine-related
presentations to an inner-city tertiary emergency department: a prospective
evaluation. Med J Aust 2007;186:336-9.
50. Morrison A, Sadler D. Death of a psychiatric patient during physical
restraint. Excited delirium--a case report. Med Sci Law 2001;41:46-50.
51. Pearlson GD. Psychiatric and medical syndromes associated with
phencyclidine (PCP) abuse. Johns Hopkins Med J 1981;148:25-33.
52. Stephens BG, Jentzen JM, Karch S, Mash DC, Wetli CV. Criteria for the
interpretation of cocaine levels in human biological samples and their relation
to the cause of death. Am J Forensic Med Pathol 2004;25:1-10.
53. Mash DC, Staley JK. D3 dopamine and kappa opioid receptor alterations
in human brain of cocaine-overdose victims. Ann N Y Acad Sci 1999;877:507-
54. Mash DC, Staley JK, Izenwasser S, Basile M, Ruttenber AJ. Serotonin
transporters upregulate with chronic cocaine use. J Chem Neuroanat
55. Stephens BG, Jentzen JM, Karch S, Wetli CV, Mash DC. National
Association of Medical Examiners position paper on the certification of
cocaine-related deaths. Am J Forensic Med Pathol 2004;25:11-3.
56. Chen L, Segal DM, Moraes CT, Mash DC. Dopamine transporter mRNA in
autopsy studies of chronic cocaine users. Brain Res Mol Brain Res
57. Berankova K, Habrdova V, Balikova M, Strejc P. Methamphetamine in hair
and interpretation of forensic findings in a fatal case. Forensic Sci Int
58. Kimura H, Mukaida M, Mori A. Detection of stimulants in hair by laser
microscopy. J Anal Toxicol 1999;23:577-80.
59. Takayama N, Tanaka S, Hayakawa K. Determination of stimulants in a
single human hair sample by high-performance liquid chromatographic method
with chemiluminescence detection. Biomed Chromatogr 1997;11:25-8.
60. Kintz P, Cirimele V, Tracqui A, Mangin P. Simultaneous determination of
amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine and 3,4-
methylenedioxymethamphetamine in human hair by gas chromatography-
mass spectrometry. J Chromatogr B Biomed Appl 1995;670:162-6.
61. Nagai T, Kamiyama S, Nagai T. Forensic toxicologic analysis of
methamphetamine and amphetamine optical isomers by high performance
liquid chromatography. Z Rechtsmed 1988;101:151-9.
62. Sztajnkrycer MD, Baez AA. Cocaine, excited delirium and sudden
unexpected death. Emerg Med Serv 2005;34:77-81.
63. O'Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am
J Forensic Med Pathol
64. Strote J, Range Hutson H. Taser use in restraint-related deaths. Prehosp
Emerg Care
65. Paquette M. Excited delirium: does it exist? Perspect Psychiatr Care
66. Gowers WR. A Manual of diseases of the nervous system 1896.
67. Nahas GG, Burks TF, Hollister LE. Drug Abuse in the Decade of the Brain
68. Levine B. Principles of Forensic Toxicology 2003:385.
69. Karch SB. Drug Abuse Handbook. 2006:1267.
70. Mets B, Jamdar S, Landry D. The role of catecholamines in cocaine
toxicity: a model for cocaine "sudden death". Life Sci 1996;59:2021-31.
71. Karch SB, Wetli CV. Agitated delirium versus positional asphyxia. Ann
Emerg Med
72. Wetli CV, Mash D, Karch SB. Cocaine-associated agitated delirium and
the neuroleptic malignant syndrome. Am J Emerg Med 1996;14:425-8.
73. Mirchandani HG, Rorke LB, Sekula-Perlman A, Hood IC. Cocaine-induced
agitated delirium, forceful struggle, and minor head injury. A further definition
of sudden death during restraint. Am J Forensic Med Pathol 1994;15:95-9.
74. Irwin P, Murray S, Bilinski A, Chern B, Stafford B. Alcohol withdrawal as an
underrated cause of agitated delirium and terminal restlessness in patients
with advanced malignancy. J Pain Symptom Manage 2005;29:104-8.
75. Morita T, Tei Y, Inoue S. Agitated terminal delirium and association with
partial opioid substitution and hydration. J Palliat Med 2003;6:557-63.
76. Morita T, Tei Y, Inoue S. Impaired communication capacity and agitated
delirium in the final week of terminally ill cancer patients: prevalence and
identification of research focus. J Pain Symptom Manage 2003;26:827-34.
77. Vatsavayi V, Malhotra S, Franco K. Agitated delirium with posterior
cerebral artery infarction. J Emerg Med 2003;24:263-6.
78. Vilke GM, Chan TC. Agitated delirium and sudden death. Prehosp Emerg
2002;6:259; author reply 259-60.
79. Frye MA, Coudreaut MF, Hakeman SM, Shah BG, Strouse TB, Skotzko
CE. Continuous droperidol infusion for management of agitated delirium in an
intensive care unit. Psychosomatics 1995;36:301-5.
80. Levenson JL. High-dose intravenous haloperidol for agitated delirium
following lung transplantation. Psychosomatics 1995;36:66-8.
81. Sanders KM, Murray GB, Cassem NH. High-dose intravenous haloperidol
for agitated delirium in a cardiac patient on intra-aortic balloon pump. J Clin
82. Verslegers W, De Deyn PP, Saerens J, Marien P, Appel B, Pickut BA,
Lowenthal A. Slow progressive bilateral posterior artery infarction presenting
as agitated delirium, complicated with Anton's syndrome. Eur Neurol
83. Mori E, Yamadori A. Acute confusional state and acute agitated delirium.
Occurrence after infarction in the right middle cerebral artery territory. Arch
84. Julien J, Vital C, Vallat JM, Bourgoin B. Epilepsy and agitated delirium
caused by an astrocytoma of the amygdala. Eur Neurol 1979;18:387-90.
85. Medina JL, Chokroverty S, Rubino FA. Syndrome of agitated delirium and
visual impairment: a manifestation of medial temporo-occipital infarction. J
Neurol Neurosurg Psychiatry
86. Medina JL, Rubino FA, Ross E. Agitated delirium caused by infarctions of
the hippocampal formation and fusiform and lingual gyri: a case report.
Neurology 1974;24:1181-3.
87. Horenstein S, Chamberlin W, Conomy J. Infarction of the fusiform and
calcarine regions: agitated delirium and hemianopia. Trans Am Neurol Assoc
88. Spiller JA, Keen JC. Hypoactive delirium: assessing the extent of the
problem for inpatient specialist palliative care. Palliat Med 2006;20:17-23.
89. Pruett JR, Rizvi ST. A16-year-old girl with excited catatonia treated with
low-dose oral Lorazepam. J Child Adolesc Psychopharmacol 2005;15:1005-
90. Kusne S, Smilack J. Transmission of rabies virus from an organ donor to
four transplant recipients. Liver Transpl 2005;11:1295-7.
91. Duggal MK, Singh A, Arunabh, Lolis JD, Guzik HJ. Olanzapine-induced
vasculitis. Am J Geriatr Pharmacother 2005;3:21-4.
92. Ogasawara K, Komoribayashi N, Kobayashi M, Fukuda T, Inoue T,
Yamadate K, Ogawa A. Neural damage caused by cerebral hyperperfusion
after arterial bypass surgery in a patient with moyamoya disease: case report.
Neurosurgery 2005;56:E1380; discussion E1380.
93. Srinivasan A, Burton EC, Kuehnert MJ, Rupprecht C, Sutker WL, Ksiazek
TG, Paddock CD, Guarner J, Shieh WJ, Goldsmith C, Hanlon CA, Zoretic J,
Fischbach B, Niezgoda M, El-Feky WH, Orciari L, Sanchez EQ, Likos A,
Klintmalm GB, Cardo D, LeDuc J, Chamberland ME, Jernigan DB, Zaki SR.
Transmission of rabies virus from an organ donor to four transplant recipients.
N Engl J Med 2005;352:1103-11.
94. Cameron D, Bridge D, Blitz-Lindeque J. Use of sedation to relieve
refractory symptoms in dying patients. S Afr Med J 2004;94:445-9.
95. Muller-Busch HC, Andres I, Jehser T. Sedation in palliative care - a critical
analysis of 7 years experience. BMC Palliat Care 2003;2:2.
96. Cowan JD, Palmer TW. Practical guide to palliative sedation. Curr Oncol
97. Cheng C, Roemer-Becuwe C, Pereira J. When midazolam fails. J Pain
Symptom Manage
98. Morita T, Tsunoda J, Inoue S, Chihara S. Terminal sedation for existential
distress. Am J Hosp Palliat Care 2000;17:189-95.
99. Travis SS, Conway J, Daly M, Larsen P. Terminal restlessness in the
nursing facility: assessment, palliation, and symptom management. Geriatr
100. Chiu TY, Hu WY, Lue BH, Cheng SY, Chen CY. Sedation for refractory
symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage
101. Ogasawara K, Ogawa A, Okuguchi T, Kobayashi M, Suzuki M,
Yoshimoto T. Postoperative hyperperfusion syndrome in elderly patients with
chronic subdural hematoma. Surg Neurol 2000;54:155-9.
102. Dunlop RJ, Campbell CW. Cytokines and advanced cancer. J Pain
Symptom Manage
103. Wein S. Sedation in the imminently dying patient. Oncology (Williston
2000;14:585-92; discussion 592, 597-8, 601.
104. Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill
patient? Support Care Cancer 1997;5:205-11.
105. Black KJ, Perlmutter JS. Septuagenarian Sydenham's with secondary
hypomania. Neuropsychiatry Neuropsychol Behav Neurol 1997;10:147-50.
106. Vaphiades MS, Celesia GG, Brigell MG. Positive spontaneous visual
phenomena limited to the hemianopic field in lesions of central visual
pathways. Neurology 1996;47:408-17.
107. Moyle J. The use of propofol in palliative medicine. J Pain Symptom
108. Di Salvo TG, O'Gara PT. Torsade de pointes caused by high-dose
intravenous haloperidol in cardiac patients. Clin Cardiol 1995;18:285-90.
109. Nicolai A, Lazzarino LG. Acute confusional states secondary to
infarctions in the territory of the posterior cerebral artery in elderly patients. Ital
J Neurol Sci
110. Sanders KM, Stern TA. Management of delirium associated with use of
the intra-aortic balloon pump. Am J Crit Care 1993;2:371-7.
111. Fernandez F, Holmes VF, Adams F, Kavanaugh JJ. Treatment of severe,
refractory agitation with a haloperidol drip. J Clin Psychiatry 1988;49:239-41.
112. Swedlow DB, Schreiner MS. Management of Reye's syndrome. Crit Care
113. Price J, Whitlock FA, Hall RT. The psychiatry of vertebro-basilar
insufficiency with the report of a case. Psychiatr Clin (Basel) 1983;16:26-44.
114. Steinhart MJ. Treatment of delirium--a reappraisal. Int J Psychiatry Med
115. Brenner WI, Lieberman AN. Acute clonidine withdrawal syndrome
following open-heart operation. Ann Thorac Surg 1977;24:80-2.
116. Wendkos M. Acute Exhaustive Mania Sudden death and psychiatric
illness. New York: Medical & Scientific Books division of Spectrum
Publications, 1979:Chapter 10.
117. Mann SC, Caroff SN, Bleier HR, Welz WK, Kling MA, Hayashida M.
Lethal catatonia. Am J Psychiatry 1986;143:1374-81.


POSSIBLE REMOVAL OF SEVERAL CONTAMINANTS FROM THE WASTEWATERS BY A NATURAL BIOFILTRATION PROCESS Binelli* A., Pogliaghi* A., Zicchinella* M., Marazzi° F., Parolini* M., Soave* C., Mezzanotte° V. *Department of Life Sciences, University of Milan, via Celoria 26, Milan (Italy) ° Department of Science of Environment and Territory, University of Milan-Bicocca, P.zza della Scienza 1, Milan (Italy)

Guidelines for Medicines Optimisation in Patients with Acute Kidney Injury in Secondary Care Caroline Ashley Marlies Ostermann Renal Pharmacist, Royal Free London NHS Consultant in Nephrology and Critical Care, Foundation Trust Guys and St Thomas' NHS Foundation Trust Sue Shaw Renal Pharmacist, Derby Teaching Hospitals NHS Foundation Trust