Transcript Tasers - University of Wisconsin School of Medicine and

Excited Delirium and
In-custody Deaths
Richard Barney, MD FACEP
Assistant Clinical Professor of
Medicine
UW Medflight
EMS Medical Director- Rock County
Beloit Memorial Hospital
1
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?

2
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.
3
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

4
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…

5
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
6
Typical Scenario

The press:
Subject “died after being shocked with taser”
 Implies cause and effect


The Fallacy: “Post hoc ergo proptor hoc”
7
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

8
Restraints and
In-Custody Deaths

What roles do physical restraint,
restraining technique and restraint position
play in excited delirium deaths?
9
Physical Restraints
Source: Prehosp Emerg Care, 2003:7(1); 48-55.
10
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

11
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.
12
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.
13
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
14
Tasers,
in and of
themselves, are not
lethal weapons.
15
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
16
Taser Effects
High voltage affects nerves
 Leads to intense muscle contraction
 Does not affect muscles directly

17
Taser Safety
215,000 officer have received
taser “ride” in training
Over 500,000 reported taser
deployments to date
No causal effects for death found
18
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

19
There is no scientific
evidence to date of a
cause and effect
relationship between
Tasers and incustody deaths.
20
Several forensic
pathology studies
have cited excited
delirium, not Tasers,
as the cause of
death.
21
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!

22
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.

23
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
24
Pathophysiology

Central nervous system effects:
Changes in dopamine transporter and
receptors
 High release of other neurotransmitters
 Accounts for behavioral changes
 Accounts for hyperthermia

25
Behavioral Components:
Delirium

Delirium:
“Off the track”
 Confusion
 Clouding of consciousness
 Shifting attention
 Disorientation
 Hallucinations
 Onset rapid – acute
 Duration brief – transient

26
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.
27
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

28
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
29
Excited Delirium

Hyperthermia

Aggravated by
 increased
activity
 the ensuing struggle
 warm humid weather (summertime)
 dehydration
 certain therapeutic medications
30
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

31
Excited Delirium:
The Usual Suspects

#1 Cause: Stimulant Drug Abuse
Acute intoxication
 Superimposed on chronic abuse
 Acute intoxication triggers the event

32
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
33
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

34
Stimulant Drugs

Other known culprits include:
Methamphetamine
 Phencyclidine (PCP)
 LSD


Cocaethylene = Cocaine + Alcohol
Toxic to the heart
 Unknown role in excited delirium deaths

35
Concurrent Health Conditions
Obesity
 Heart Disease

Coronary artery disease
 Cardiomegaly
 Hypertrophic cardiomyopathy
 Myocarditis
 Fibrotic heart

36
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
37
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

38
Excited delirium is
an imminently lifethreatening medical
emergency.
39
The behavioral
features of excited
delirium include
criminal acts, but…
40
Excited delirium is
not a crime in
progress, and
responders must
recognize the
difference, before it’s
too late.
41
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

42
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)

43
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

44
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

45
Patients with excited
delirium need rapid
aggressive medical
intervention.
46
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 (no restraints?)
Minimize struggle and restraints
Unrealistically simplified?? – Maybe!
47
The first goal of
therapy is to gain
control of the violent
behavior.
48
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

49
In Search of The “Ideal” Drug
Benzodiazepines
 Neuroleptics
 Atypical antipsychotics
 Ketamine

50
Benzodiazepines
Effective
 But usually require repeat doses
 Adverse reactions:

Hypotension
 Respiratory Depression
 Too long to take effect
 Over sedation

51
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
52
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

53
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!
54
The second goal of
therapy is to
stabilize the
underlying
pathophysiologic
processes.
55
Immediate Exam
Core temperature
Blood gas
CBC and electrolytes
Stat glucose
Toxicology
EKG
Urine for myoglobin
CPK
56
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
57
Psychiatric History
Diagnosis
 On Meds?
 Has patient stopped meds?
 Schizophrenia
 Personality disorder
 Manic disorder

58
Summary
Excited Delirium is an imminently
life threatening medical emergency,
not a crime in progress
 In-custody deaths likely related to
excited delirium
 Tasers – if used early – may help
(remains unproven)
 ALS medics can give potent
tranquilizers
 Rapid aggressive medical

59
Summary
Beware of potential side effects of
therapeutic drugs
 Treat for hyperthermia, dehydration,
metabolic acidosis and potential
hyperkalemia

60