ACEP Recognizes Excited Delirium Syndrome

Abstract

The American College of Emergency Physicians formally recognized excited delirium as a unique syndrome on Sunday, taking an initial step toward identifying its causes and preventing the deaths that can occur in these patients. Excited Delirium Syndrome (ExDS) has long been the sole purview of medical examiners, largely because the syndrome is often only diagnosed on autopsy. But as Mark L. DeBard, MD, the chairman of the ExDS Task Force, said, ACEP’s approval of the task force white paper allows emergency physicians not only to recognize the syndrome and save lives, but to force it into the consciousness of law enforcement and emergency medical services. “I want emergency physicians around the country to know that most of the time they’re treating these cases successfully, but this allows the medical community to call it by name,” he said. “That’s the first step, and we need case reports to identify its characteristics.” Patients with excited delirium are challenging to everyone involved in their care, often leaving police and health care providers struggling to control their aggressive behavior rather than treating their medical condition, one that could suddenly end in death. The task force members found themselves facing a dilemma much like the decades-long one over sudden infant death syndrome: Researchers and clinicians argued whether ExDS was even a syndrome, essentially because no clear definition or cause exists. The exact pathophysiology remains unidentified, the task force noted in a white paper it presented to the ACEP Council and Board of Directors during this year’s Scientific Assembly. And although the syndrome is not always fatal, many patients experience cardiac arrest and death. About 250 patients die in the United States each year from ExDS, an estimated eight to 14 percent of those who experience the syndrome, said Dr. DeBard, a professor of emergency medicine at Ohio State University College of Medicine and a past ACEP speaker and board member. The task force called for identifying those whose deaths might be averted with early intervention. And that starts with identifying the triad of conditions that are the hallmark of ExDS: delirium, psychomotor agitation, and phy siological excitation. A typical ExDS patient usually has acute drug intoxication, usually from cocaine, or less often has a serious history of mental illness on multiple medications. Because the syndrome is marked by aggressive and erratic behavior — being extremely combative and ripping off their clothes, for instance — the police often become involved and use physical or chemical control measures, sometimes a conducted electrical weapon (CEW). Mainstream media have often pointed to CEWs, commonly called TASERs, as the cause of these deaths while emergency physicians often think the syndrome is acute cocaine intoxication. But Dr. DeBard, also an attending at Ohio State University Hospital East, said