Case of the Month
October 2007

27-year-old male – bizarre and aggressive behavior

Dispatch
"Aid 87, stage for police – 27-year-old male, bizarre behavior”

En route your crew discusses the following considerations:

• Scene safety and proper staging distance
• Psychological issues
• Medical reasons for altered level of consciousness

While en route to the scene the dispatcher alerts you that police are on the scene and the patient has been restrained; however, they are requesting a medical evaluation. A medic unit has been dispatched. (In King County, a request from law enforcement for possible excited delirium triggers a medic response.)

Scene Size-up
Your crew arrives at the scene and you are met by a police officer.  She states that the patient broke into a home and began this bizarre behavior.  When the homeowner confronted him he started “tearing the place apart.”  The homeowner called police-- it took five officers to restrain the patient.  He is handcuffed and hobbled (feet tied together) and is still agitated.  The police are concerned drugs might be involved.  This individual has been involved frequently in police responses involving methamphetamine use and dealing.  She adds that the suspect may be experiencing excited delirium.

Initial Assessment
You find the patient lying prone on the ground with his feet tied and his hands cuffed behind his back.  He is naked and sweating profusely.  His eyes are wide open and he is talking and yelling, but not making sense.  Even though the handcuffs are not tight there is a small amount of blood from minor abrasions and lacerations.  The patient continues to struggle even though the officers have stepped back. 

You ask if there is a history of a head injury or fall and the police officer responds that none was reported or seen.   A quick visual survey of the patient finds a few abrasions and small lacerations, but no obvious major trauma.

Initial Treatment
Because the patient is writhing around it is difficult to initiate treatment.  You move him to a stretcher and apply the straps to confine him.  As you are applying the straps he tries to resist.  You are able to get vital signs and a blood sample for glucometry; however, attempts at administering oxygen are futile.  His skin feels very warm to the touch.

Vital Signs

• Respirations             30 to 40/min
• Pulse                      140/min
• Mental status           Fully alert, speaking incoherently
• Blood pressure          150/Palp
• Glucometry              89 mg/dl

Further Evaluation and Treatment
Within five minutes of the patient being placed on your stretcher you notice that he goes limp.  You check for respirations and find there are none.  Your partner begins to administer ventilations with a BVM --you update the incoming medic unit and call for an engine company for additional support.  You ask a police officer to remove the hand cuffs and help move the patient to a firm surface.  A carotid pulse check reveals cardiac arrest—your team begins CPR.  Soon, additional medical personnel arrive; however, after 40 minutes of CPR and IV drug therapy, the patient is pronounced dead at the scene.

Excited Delirium
Excited delirium is a relatively new term used by police and medical personnel to describe an uncommon but potentially dangerous condition.  It refers to individuals whose behavior present with:

• Out-of-control behavior
• Paranoia
• Fear
• Confusion
• Violent resistance to restraint

Physical findings may include:

• High core temperature
• Sweating
• Shouting
• Unusual strength
• Imperviousness to pain

Often these individuals have a history of stimulant abuse, such as methamphetamine or cocaine or, to a lesser extend, PCP.  Although, not usually fatal, they may experience sudden, unexpected cardiac arrest.   The physiology of this phenomenon is still being researched. Virtually all cases occur in males.

Perhaps, in the past, you may have heard of or have seen someone who keeps fighting even though they have been shot with a Taser or have painful injuries; this example of an unbelievable strength and tolerance to pain may have been a case of excited delirium.  These patients are extremely dangerous.

If you suspect someone is experiencing excited delirium you should retreat and await the arrival of law enforcement.  Must realize that there is a potential for cardiac arrest. 

Approach the patient in a manner that is safe for your and those around you.  If the patient is conscious, perform a physical exam as best you can while staying safe.  ALS should be called for all cases of excited delirium as these patients may experience lethal dysrhythmias and go into cardiac arrest. All patients with suspected excited delirium should undergo constant cardiac monitoring. 

View more information on excited delirium
Wikipedia (external link)