The Medicolegal Evaluation of Excited Delirium

Abstract

Excited delirium is a life-threatening syndrome that may be initiated by a variety of causes including drug intoxications and psychiatric illnesses. People in an excited delirium may demonstrate paranoid, aggressive, and incoherent behavior. Due to their actions, people in an excited delirium may come to the attention of law enforcement. The challenge for the forensic pathologist arises when these deaths occur during or shortly following a violent struggle, often involving law enforcement agents. Three instances of excited delirium are described to demonstrate further the syndrome and to serve as a basis for the discussion of the medicolegal aspects of excited delirium. There are several theories for this syndrome and much attention has been given to the role of restraint and struggle. In addition to asphyxial mechanisms, other neurochemical abnormalities involving dopamine, elevated potassium concentrations, lactic acidosis, and increased catecholamine effects on the heart have been examined. Cocaine and amphetamine are two of many substances that may cause the syndrome of excited delirium. The goal of the autopsy in suspected excited delirium deaths is to identify (or exclude) a disease or injury sufficient to explain a sudden death in the context of the investigated circumstances. In deaths due to excited delirium, there is no pathognomonic autopsy finding and minor injuries (abrasions, contusions, cuts) are typical. Due to the complex physiologic, chemical, environmental, and traumatic interactions that occur, there is perhaps no other type of death in which it is so important to apply the forensic maxim that each death must be evaluated “one at a time”. The roles of restraint, electromuscular disruption devices (e.g., Tasers®), mechanical trauma, stress, and natural disease must be considered in the certification of death.