Transcript Tasers - PHARM

Excited Delirium and
In-custody Deaths
Michael Abernethy MD FAAEM
Assoc Professor of Emergency Medicine
Univ of Wisconsin SMPH
1
Objectives
Excited Delirium
 Physical Restraints & Use of TAZERS
 Medical Management

2
In-Custody Deaths…
Why do some people die following a
violent confrontation with police?
 What role does the taser play, if any?
 What role does position of the patient play
 What can police officers do to prevent incustody deaths?
 What is EMS Role?
 What is the ER Role?

3
Case #1
“Willie went ape shit”
4
Typical Scenario
Male subject creating a disturbance
 Triggers 911 call
 Obvious to police that subject will resist
 Struggle ensues with multiple officers


May involve OC, Taser, choke holds, batons,
etc.
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Typical Scenario

Physical restraints applied
Subject subdued in a prone position
 Officers kneeling on subjects back
 Handcuffs, ankle cuffs
 Hogtying, hobble restraint

Prone vs. lateral positioning
 Transported in a squad car to jail

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Typical Scenario

Continued struggle against restraints


Sometimes damages squad car
Apparent resolution period
Subject becomes calm or slips into
unconsciousness
 Labored or shallow breathing
 Followed unexpectedly by…

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Typical Scenario

Death
Resuscitation efforts are futile
 Los Angeles County EMS Study
 18 ED deaths witnessed by paramedics (all
were restrained)
 In 13 – rhythm documented
 VT and asystole were most common

 No
 All
ventricular fibrillation
failed resuscitation
Source: Am J Emerg Med; 2001:19(3), 187-191
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Typical Scenario

The press:
Subject “died after being shocked with taser”
 Implies cause and effect


The Fallacy: “Post hoc ergo proptor hoc”
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Typical Aftermath

Several weeks later – autopsy results…

Cause of Death
 Excited
delirium
 Illicit stimulant drug abuse
 Concurrent medical problems
 Minimal injury from police confrontation
It wasn’t the taser after all
 Officers exonerated

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Restraints and
In-Custody Deaths

What roles do physical restraint,
restraining technique and restraint position
play in excited delirium deaths?
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Physical Restraints
Source: Prehosp Emerg Care, 2003:7(1); 48-55.
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Physical Restraint Issues

Positional Asphyxia
Deaths have occurred with subjects
restrained in a prone position
 Theory: restricts breathing
 The role of the position is unclear
 Little data to support causality
 Other factors are the likely culprits

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Physical Restraint Issues

No clinically significant changes in
pulmonary function tests in healthy
volunteers

Am J Forensic Med Pathol. 1998
Sep;19(3):201-5.
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Physical Restraint Issues

Restraint Asphyxia


Increased deaths in restrained patients
Rat Study





3 fold increase in cocaine-related deaths among “restrained”
rats
Life Sci. 1994;55(19):PL379-82.
Numerous studies now show restraint position not
causative of death
Routinely now rejected in the courts
It isn’t the restraint that kills them, it is the Excited
Delirium.
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Physical Restraint Issues

Compression asphyxia

What are the adverse effects on breathing
and circulation when one or more officers
kneel on the subjects back as they handcuff
him?
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Thomas A. Swift’s Electric Rifle
(TASER)
Source:
http://www.pointshooting.com/m26black.jpg
Source: http://www.keme.co.uk/~mack/M26.jpg
M26 Taser. Manufactured by Taser International
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Tasers,
in and of
themselves, are not
lethal weapons.
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Tasers Use Electricity
It’s not the voltage it’s the amperage that
is dangerous
 Tasers use high voltage, but very low
amperage

M26: 3.6 milliamps (average current)
 M26:1.76 joules per pulse
 X26: 2.1 milliamps (average current)
 X26: 0.36 joules per pulse


X26 Taser delivers 19 pulses per second
19
Taser Effects
High voltage affects nerves
 Leads to intense muscle contraction
 Does not affect muscles directly

20
Taser Safety
215,000 officer have received
taser “ride” in training –
Myself included
Over 500,000 reported taser
deployments to date
No causal effects for death found
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Taser Red Flag
If anyone exhibits behavior that
requires more than 3 taser
deployments in order to gain
restraint/control – it is a Medical
emergency until proven otherwise
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Academic Emer. Med. 2006
June;13(6):589-95

After 5 second taser ride on numerous
subjects:
No EKG changes
 No cardiac cell injury
 No hyperkalemia
 No acidosis

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There is no scientific
evidence to date of a
cause and effect
relationship between
Tasers and incustody deaths.
24
Several forensic
pathology studies
have cited excited
delirium, not Tasers,
as the cause of
death.
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What is Excited Delirium?
An imminently life threatening medical
emergency…
 Massive release of epinephrine,
norepinephrine, dopamine, serotonin in
the body and brain.
 Severe delirium and agitation
 Not a crime in progress!

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The “Freight Train to Death”
How police restrain or position the subject
will not stop “the freight train to death”
 The sooner the severe agitation is
terminated, the better
 This requires EMS response and transport
to the hospital.

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What is Excited Delirium?

Diagnostic criteria




Characteristic behavioral components
Metabolic Acidosis
Hyperthermia
Identifiable cause




Stimulant drugs
Psychiatric disease
Alcohol or medical problems rarely can cause
It does not explain all behavior that leads to
confrontation with police
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Pathophysiology

Central nervous system effects:
Changes in dopamine transporter and
receptors
 High release of other neurotransmitters
 Accounts for behavioral changes
 Accounts for hyperthermia

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Behavioral Components:
Delirium

Delirium:
“Off the track”
 Confusion
 Clouding of consciousness
 Shifting attention
 Disorientation
 Hallucinations
 Onset rapid – acute
 Duration brief – transient

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Behavioral Components:
Excited (Agitated)

Extreme agitation, increased activity

Aggravated by efforts to subdue and restrain

Not likely to comply after one or two tasers

Pressured speech, grunting

Inappropriate words and flight of ideas.
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Behavioral Components:
Excited (Agitated)

Violent or aggressive behavior
Towards inanimate objects, especially
smashing glass
 Towards self, others or police

Noncompliant with requests to desist
 Superhuman strength
 Insensitive to pain

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Excited Delirium

Hyperthermia
High body temperature
 105 – 113 oF
 Drug’s effect on temperature control center in
brain (hypothalamus)
 Tell-tale signs:

 Profuse
sweating
 Undressing – partial or complete
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Excited Delirium

Hyperthermia

Aggravated by
 increased
activity
 the ensuing struggle
 warm humid weather (summertime)
 dehydration
 certain therapeutic medications
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Excited Delirium

Metabolic Acidosis

Potentially life threatening
 Elevated


blood potassium level
Factors: dehydration, increased activity
Survivors:
Kidney damage due to muscle breakdown
 May require dialysis

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Excited Delirium:
The Usual Suspects

#1 Cause: Stimulant Drug Abuse
Acute intoxication
 Superimposed on chronic abuse
 Acute intoxication triggers the event

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Excited Delirium:
The Usual Suspects

Underlying psychiatric disease
First described in 1849 before cocaine was
first extracted from cocoa leaf
 Mania (Bipolar Disorder)
 Psychosis (Schizophrenia)


Noncompliance with medications to control
psychosis or bipolar disorder


Unusual – #2 Cause
Rare: New onset schizophrenia
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Stimulant Drugs

Cocaine
The major offender
 On the rise due to “crack epidemic”


Toxicology studies show…
Low to moderate levels of cocaine
 High levels of benzoylecognine (the major
breakdown product of cocaine)
 Suggests recent use superimposed on
chronic abuse

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Stimulant Drugs

Other known culprits include:
Methamphetamine
 Phencyclidine (PCP)
 LSD


Cocaethylene = Cocaine + Alcohol
Toxic to the heart
 Unknown role in excited delirium deaths

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Concurrent Health Conditions
Obesity
 Heart Disease

Coronary artery disease
 Cardiomegaly
 Hypertrophic cardiomyopathy
 Myocarditis
 Fibrotic heart

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Autopsy Proof
Specialized laboratories can identify
changes in brain chemistry that are
characteristic of excited delirium
 Blood and brain tissue levels of
benzoylecognine and cocaine


Typical ratio 5:1
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Tasers and
Excited Delirium Deaths
It’s not the Taser
 Many in-custody deaths long before tasers
were ever used



Documented in 1980s medical literature
Deaths of persons not in custody
Found naked in bathrooms
 Wet towels
 Empty ice cube trays scattered about
 A futile effort to cool themselves

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Excited delirium is
an imminently lifethreatening medical
emergency.
43
The behavioral
features of excited
delirium include
criminal acts, but…
44
Excited delirium is
not a crime in
progress, and
responders must
recognize the
difference, before it’s
too late.
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Recognizing Excited Delirium

Agitation or Excitement = Increased
activity and intensity
Aggressive, threatening or combative – gets
worse when challenged or injured
 Amazing feats of strength
 Pressured loud incoherent speech
 Sweating (or loss of sweating late)
 Dilated pupils/less reactive to light
 Rapid breathing

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Recognizing Excited Delirium

Delirium = Confusion

Disoriented
 Person,

place, time, purpose
Rapid onset over a short period of recent
time
 “He
just started acting strange”
Easily distracted/lack of focus
 Decreased awareness and perception
 Rapid changes in emotions (laughter,
anger, sadness)

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Recognizing Excited Delirium

Psychotic = bizarre behavior
Thought content inappropriate for
circumstances
 Hallucinations (visual or auditory)
 Delusions (grandeur, paranoia or reference)
 Flight of ideas/tangential thinking
 Makes you feel uncomfortable

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Bad Behavior: Other Reasons
Alcohol intoxication or withdrawal
 Other drug use problems


Example: Cocaine psychosis
Pure psychiatric disease
 Head injury
 Dementia (Alzheimer’s Disease)
 Hypoglycemia
 Hyperthyroidism

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Patients with excited
delirium need rapid
aggressive medical
intervention.
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Alternative Strategy









Attempt verbal de-escalation
Summon back-up quickly
Summon EMS as early as possible
Use taser before a struggle ensues
Jump the subject and administer tranquillizer
Back off and contain the subject without restraint
Once calm transport
Minimize struggle and restraints
Unrealistically simplified?? – Maybe!
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The first goal of
therapy is to gain
control of the violent
behavior.
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The “Ideal” Drug

Rapid effective tranquilization


No repeat dosing
No significant adverse effects
respiratory depression
 cardiovascular depression
 neurological adverse effects

Easy to administer (IM)
 Allows easy assessment of neurological
status on ED arrival

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In Search of The “Ideal” Drug
Benzodiazepines
 Neuroleptics
 Atypical antipsychotics
 Ketamine

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Benzodiazepines
Effective
 But usually require repeat doses
 Adverse reactions:

Hypotension
 Respiratory Depression
 Too long to take effect
 Over sedation

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Neuroleptics and
Atypical Antipsychotics

Rapid onset (10 – 15 minutes or less)




Do we have 15 minutes?? NO
Can be very effective in a single dose
Prolong the QT Interval (Droperidol)
Target dopamine D2 receptors

May exacerbate hyperthermia

HALDOL or GEODON
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Ketamine
Very rapid onset of action (<5 minutes)
 Highly effective in a single dose
 Favorable safety profile in healthy patients
 Potential adverse effects:

Adrenergic over stimulation in excited delirium
 “Emergence reactions” in adults
 Dose 3-4 mg/Kg IM

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Rapid Chemical Sedation is
Life-saving
Get a chemical restraint drug into
the patient at once.
Remove physical restraints when
feasible
Never allow hobble or prone
restraint!
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The second goal of
therapy is to
stabilize the
underlying
pathophysiologic
processes.
59
Immediate Exam
Core temperature
Blood gas
CBC and electrolytes
Stat glucose
Toxicology
EKG
Urine for myoglobin
CPK
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Immediate Treatment

Dehydration/Metabolic Acidosis:


Hyperthermia:


IV NS X 2 W/O Get ABG Bicarb for under 7.0
Cool environment, disrobe, tepid mist and
fanning, cooling blankets
Hyperkalemia?:

Fluids, Calcium Chloride, Sodium
Bicarbonate, Albuterol
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Psychiatric History
Diagnosis
 On Meds?
 Has patient stopped meds?
 Schizophrenia
 Personality disorder
 Manic disorder

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Summary
Excited Delirium is an imminently life
threatening medical emergency, not a
crime in progress
 In-custody deaths likely related to excited
delirium
 Tasers – Very useful to gain physical
control as an alternative to physical force
 ALS medics can give potent tranquilizers
 Rapid aggressive medical stabilization
needed

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Summary
Beware of potential side effects of
therapeutic drugs
 Treat for hyperthermia, dehydration,
metabolic acidosis and potential
hyperkalemia

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Consider Exited Delirium as
Cause of Death
Severe struggle with police with
heavy restraint policy used
Sudden collapse and death
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ED as Cause of Death
Toxicology positive for stimulant drugs
 Hyperthermia at time of death
 Severe acidosis
 Rhabdomyolysis
 Water all over the scene
 Broken glass
 Heart or lung disease on autopsy

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