A New Lens on Excited Delirium

Set aside, for a moment, the question of whether excited delirium is real—few in EMS dispute that. A more current and provocative question might be, “Is it racist?”

In the larger world of medicine, the diagnosis of excited delirium is falling out of favor. There are multiple reasons for that, including some very good clinical ones that are probably sufficient by themselves. But they’re accompanied also by certain racial baggage that has surrounded the diagnosis since its beginning and clouds its usefulness today. 

If that baggage impedes the cause of helping vulnerable patients—or, worse, contributes to their harm—reconsidering it seems not only appropriate but imperative. Some leading organizations have begun doing so—seeking new terminology or better ways to describe the condition. 

“If someone said to me, ‘Come on, doc—who cares what we call it?’, well, the reality is that a lot of people care,” says Oklahoma emergency physician and EMS medical director Jeff Goodloe, MD, FACEP, who was part of an American College of Emergency Physicians (ACEP) task force that produced a 2021 report on caring for patients with what it rechristened hyperactive delirium with severe agitation. 

“Maybe it doesn’t seem like a big deal to someone who hasn’t had the experiences some of our patients have had—‘just call it whatever.’ But some of the options among those whatevers can be hurtful to people—hurtful emotionally, hurtful to their sense of community, and hurtful to their sense of safety. And they can be hurtful to their sense of trust in us. And when we lose the trust of the public, what do we have left? That trust has to be there for the care that follows.”

A Disease Name

Among major medical bodies, the American Psychiatric Association in 2020 was one of the first to rethink the excited delirium diagnosis, which it called “too nonspecific to meaningfully describe and convey information about a person.”¹ The APA also noted ExD had been “invoked in a number of cases to explain or justify injury or death to individuals in police custody, and the term excited delirium is disproportionately applied to Black men in police custody.”

The American Medical Association followed in June 2021, citing “a pattern of using the term ‘excited delirium’ and pharmacological interventions such as ketamine as justification for excessive police force, disproportionately cited in cases where Black men die in law enforcement custody.”² 

While the focus of its 2021 paper was patient care, ACEP acknowledged the influence of such concerns on the discussion and in its rewording. Its task force, which included several prominent EMS physicians, noted:

“Critics of this [excited delirium] terminology have raised concern that it has been employed to explain away preventable in-custody deaths as inevitable outcomes, without proper consideration of other contributing factors and alternative management strategies that might have resulted in survival… Moreover, the term is only definitively applied as a postmortem cause of death, rather than prospectively at presentation. Given the increasingly charged nature of the term, ACEP is concerned that its use in this document may distract from the intended delivery of critical information.”³ 

“A lot of the controversy is just about nomenclature. So we decided, OK, let’s change the nomenclature,” says Goodloe, also a professor of emergency medicine and EMS section chief in the Department of Emergency Medicine at the University of Oklahoma School of Community Medicine. “We changed it not because people in psychiatry or anesthesiology don’t like it. We changed it because words matter. And the words we have been using have, unknowingly to most of us, been more hurtful to more people than we realized until now.”

While it’s far from a groundswell, some other quarters of EMS are thinking similarly. 

In a March video Nick Simpson, MD, chief medical director for Minneapolis-based Hennepin EMS, explained why the service and its associated health care system decided on new framing.⁴ He observed excited delirium meant different things to different people and that oversimplifying a complex concept has led to confusion. Additionally, he noted, some of the characteristics of excited delirium cited in a 2009 ACEP white paper—pain tolerance, lack of tiring, unusual strength (see Figure 1)⁵—could be dehumanizing and contribute to exaggerated fear and increased use of force by responders. Another attribute, police noncompliance, could carry legal implications. 

In Colorado the panel charged with reviewing ketamine use in the state following the death of Elijah McClain urged not just renaming but rejection of the excited delirium diagnosis.⁶ While primarily focusing on ketamine issues, it noted terms like hyperaggression, increased strength, and police noncompliance have been associated with racial bias against Black men and can underlie “discriminatory practices that result in systemic bias against communities of color.” It also cited the lack of uniform definition and specific validated criteria to support the ExD diagnosis.

“The main challenge that led us to conclude excited delirium was not a good diagnosis and indication for ketamine is that it can’t be confirmed in the field,” says Scott Bourn, PhD, RN, a senior quality consultant for ESO Solutions and longtime EMS executive who was part of the panel. “It’s like saying to paramedics, ‘We want you to give this medication for a cardiac rhythm you can’t diagnose.’ 

“When you look at the hallmark signs, they’re not specific. Extreme agitation, OK, that’s pretty easy. But delirium versus disorientation and confusion—that’s a tough call to make definitively when a patient’s swinging and screaming at you. We’re not checking body temperatures for hyperthermia because they’ll kick our butts. Superhuman strength—what exactly does that even mean? 

“So at the end of the day, we concluded excited delirium was a diagnosis. And it’s a controversial diagnosis; there are certainly physician groups that don’t think it exists. But in EMS we’re giving the medication [ketamine] to solve a problem, not treat a disease. So let’s define the problem and not use a disease name.”

While the Colorado panel was convened following the in-custody death of McClain, its review wasn’t case-based—it looked at the big evidentiary picture, not individual incidents. It nonetheless identified a racial element that compounded the diagnosis’ other shortcomings.

“We ultimately concluded it wasn’t a useful diagnosis partly because you can’t really diagnose it in the field,” Bourn adds, “and partly because when you go back historically and look at the signs and symptoms, they’re extraordinarily racially biased.”

‘Drug Fiends’

While a similar condition was described by American physician Luther Bell in the mid-19th century, the term excited delirium was first used by Florida pathologist Charles Wetli in the 1980s. In a 1981 case report describing the death of a cocaine “packer” (someone who conceals the drug intracorporeally), he and colleague David Fishbain referenced two subtypes of delirium, stuporous and excited.⁷ Four years later he reported on “fatal cocaine intoxication presenting as an excited delirium” in a small number of recreational users in South Florida who “raged wildly,” then abruptly died.⁸  

But those subjects didn’t have enough cocaine in their systems to kill them—their blood concentrations averaged 10 times lower than what’s seen in fatal overdoses. So as the bodies piled up across Miami throughout the ’80s—Black women, mostly prostitutes and chronic cocaine users with signs of recent sexual activity—Wetli came to believe there was something different about the cocaine…or, eventually, about the users. “My gut feeling,” he told the Miami New Times in 1989, “is that this is a terminal event that follows chronic use of crack cocaine affecting the nerve receptors in the brain.”⁹

“For some reason,” he later told the Miami News, “the male of the species becomes psychotic [after chronic cocaine use], and the female of the species dies in relation to sex.”

Then a 14-year-old girl turned up dead with no cocaine in her system. This prompted a review by the chief medical examiner, who determined the women—by that point 19 of them—had been murdered, with evidence of asphyxia.¹⁰ Police identified a suspect, Charles Williams, and charged him with one of the killings, but he died before going to trial.

Whatever Wetli may have observed, his conclusions recalled some ugly historical racist tropes about Black people and drugs, such as physician Edward Huntington Williams’ 1914 New York Times description of “negro drug fiends” who were lethally dangerous and impervious to deadly force.¹¹ 

And 40 years later racial disparities persist around the diagnosis. 

“From the beginning,” a 2020 Brookings review found, “this terminology has been disproportionately applied to Black people and has only been used in specific contexts pertaining to encounters with law enforcement.”¹²  

A systematic review published in 2018 judged the overall quality of literature on excited delirium poor but found “male sex, young age, African-American race, and being overweight” as independent risk factors.¹³ An older study looking at cocaine-related deaths found them more likely diagnosed as excited delirium among young Black men and accidental cocaine toxicity in White people.¹⁴ Abundant literature has documented greater uses of police force with Black Americans, and a 2020 review found deaths from excited delirium syndrome so associated with aggressive restraint that it concluded, “There is no evidence to support ExDS as a cause of death in the absence of restraint.”¹⁵ 

A Different Dynamic

It’s no coincidence that the jurisdictions on the front edge of this issue for EMS, Minneapolis and Colorado, both experienced recent high-profile deaths of Black men in police custody where excited delirium was at issue. In Colorado its diagnosis in the McClain case was questioned in the city of Aurora’s independent report following his death (McClain had no illegal drugs in his system),¹⁶ and in Minnesota it failed as a defense for the officers convicted in George Floyd’s killing.¹⁷ 

These cases and others haven’t exactly quelled suspicions that ExD may be, for some, a vague and open-ended license to use excessive force and a catchall diagnosis that obscures other causes of death. That was surely not the intent of the authors of ACEP’s 2009 white paper, but by today’s standards it’s conceivable how their defining characteristics might now, especially taken in sum, paint a somewhat dehumanizing picture of a patient.

ACEP’s 2021 paper is neither an update nor a refutation of the 2009 paper, Goodloe emphasized, but a work based on more current evidence that should fully replace the earlier document. 

“We want to be respectful of our colleagues who put their best efforts into writing that paper back in 2009, but that paper was never formally adopted by ACEP and is not utilized by ACEP today,” he says. “That was written at a different time, in a different dynamic, and I honestly don’t think information in that report should be used to inform or educate today.”

A New Guideline 

None of this is to say that states of extreme agitation and altered mental status don’t exist, or that using the term excited delirium to describe a patient in 2022 makes you racist. But words matter, and perhaps there’s a phrasing that’s more patient-friendly—less adversarial and more conducive to the high level of care these desperately sick patients need. 

As far as that care, both ACEP and the Colorado panel provided some guidance. ACEP’s 2021 paper set forth 7 main principles:

• Hyperactive delirium with severe agitation is an acute life-threatening medical condition that demands emergency medical treatment. 
• Patient safety must be the primary focus of emergency medical treatment. 
• Restoring normal body physiology, facilitating a safe environment, and providing the opportunity to differentiate and treat life-threatening causes of hyperactive delirium are the patient-centered goals of treatment. 
• De-escalation techniques may be effective; try them when possible. 
• Parenteral medications are often required; ketamine, droperidol, olanzapine, and midazolam are best supported by current literature. 
• Medical treatment of hyperactive delirium with severe agitation should be led by a physician board-certified in EMS and/or emergency medicine.
• Additional research is needed to more fully understand inciting pathways and pathophysiology of individual causes. 

Colorado’s panel offered a host of recommendations around the use of ketamine, including the indications for, dosing of, and monitoring of chemical restraint; changes to paramedic education and training; and improvements in state and local oversight. Beyond transcending the ExD diagnosis, it urged the state to examine whether there’s disproportionate responder ketamine use for marginalized persons and communities of color and assess the equity impact of the state’s ketamine waiver process. 

“First, we concluded that ketamine is a safe drug,” says Bourn. “No. 2, excited delirium is not a useful diagnostic category for us. Instead let’s consider that ketamine is a medication to be considered for patients who require hospital evaluation and treatment and are too agitated and combative to get there safely. If there are patients who are so agitated and disoriented that we cannot safely assess, treat, and transport them to definitive care, we don’t need to worry about whether it’s ‘excited delirium.’

“With those two pieces, together with efforts to use a set dose rather than a weight estimation for dosing, taken together you have the essence of what could be a new treatment guideline.”

A Purposeful Use of Words

Whatever you call it, excited delirium syndrome is dangerous, with a fatality rate of 8.3%–16.5%.¹³ That’s plenty of reason to work to optimize care of these difficult patients. Moving beyond current framing may be part of that optimization—for “politically correct” reasons, sure, but even more for clinical. 

“My recommendation to local communities is that they revisit how they manage these patients and eliminate the term excited delirium not because it’s politically objectionable—although it probably is—but because it’s a poor diagnosis and a diagnosis we can’t definitively make in the field,” says Bourn. “Let’s focus instead on what I think we’re really trying to achieve, which is the safe assessment, care, and transport of patients who are agitated but require hospital assessment and management.”

“If we look at this through the lens of the American College of Emergency Physicians, is the terminology the most important thing? Is that what we want to quibble about?” asks Goodloe. “I think for all of us the answer is absolutely not. We want the focus to be on the patient. So let’s not get our energy all spun up and expended on semantics.

“This is about caring for others. And sometimes caring for others is a very purposeful use of words.”

Sidebar: The Case Against ExDS

“ExDS lacks a consensus definition, a specific diagnostic test, clearly understood pathophysiologic mechanisms, and verifiable clinical indications that can be applied to reach a reliable diagnosis. Even organizations that recognize the diagnosis concede that the unique indications assigned to ExDS are difficult to specify since the characteristics of the syndrome overlap with many other clinical diseases. To complicate matters, the medical community can neither clearly classify the cause[s] of the syndrome nor provide a coherent explanation as to why ExDS may lead to sudden death. In fact, forensic pathologists and coroners have assigned ExDS as a cause of death when other existing conditions are not readily apparent. Relevant professional organizations disagree whether an ExDS diagnosis can only be confirmed post-mortem. Compounding all of these difficulties are the facts that these diagnoses are exceedingly rare, are usually dependent on subjective descriptions of the patient’s symptoms, and almost always fail to recognize the contribution of physical restraint and positional asphyxia as potential contributors of death in these lethal situations.” 

—Final Report, Colorado Ketamine Investigatory Review Panel

References

1. American Psychiatric Association. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. Published December 2020.

2. American Medical Association. New AMA policy opposes “excited delirium” diagnosis. Published June 14, 2021. www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis

3. Hatten BW, Bonney C, Dunne RB, et al. ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings. American College of Emergency Physicians. www.acep.org/by-medical-focus/hyperactive-delirium/

4. Simpson N. EMS and Law Enforcement video. Hennepin Healthcare. Accessed April 12, 2022. www.hennepinhealthcare.org/mpd-video/

5. DeBard ML, Adler J, Bozeman W, et al.; ACEP Excited Delirium Task Force. White Paper Report on Excited Delirium Syndrome. Published September 10, 2009. www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome 

6. Ketamine Investigatory Review Panel. Final Report. Colorado Department of Public Health & Environment. Published December 1, 2021. https://cdphe.colorado.gov/ketamine-investigatory-review-panel-report-overview 

7. Fishbain DA, Wetli CV. Cocaine intoxication, delirium, and death in a body packer. Ann Emerg Med. 1981; 10(10): 531–2. doi: 10.1016/s0196-0644(81)80010-8

8. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci. 1985; 30(3): 873–80. PMID: 4031813

9. Garcia-Roberts G. Is excited delirium killing coked-up, stun-gunned Miamians? Miami New Times. Published July 15, 2010. Accessed April 13, 2022. www.miaminewtimes.com/news/is-excited-delirium-killing-coked-up-stun-gunned-miamians-6367399 

10. Bhatia BD, Heisler M, Naples-Mitchell J, Saadi A, Sherwin J. “Excited Delirium” and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis. Physicians for Human Rights. Published March 2022. https://phr.org/our-work/resources/excited-delirium/ 

11. Williams EH. Negro Cocaine “Fiends” Are a New Southern Menace. New York Times. Published February 8, 1914. Accessed April 13, 2022. www.nytimes.com/1914/02/08/archives/negro-cocaine-fiends-are-a-new-southern-menace-murder-and-insanity.html

12. Budhu J, O’Hare M, Saadi A. How “excited delirium” is misused to justify police brutality. Brookings. Published August 10, 2020. www.brookings.edu/blog/how-we-rise/2020/08/10/how-excited-delirium-is-misused-to-justify-police-brutality/ 

13. Gonin P, Beysard N, Yersin B, Carron P-N. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018; 25(5): 552–65. doi: 10.1111/acem.13330

14. Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J Forensic Sci. 1997; 42(1): 25–31.

15. Strömmer EMF, Leith W, Zeeger MP, Freeman MD. The role of restraint in fatal excited delirium: a research synthesis and pooled analysis. Forensic Sci Med Pathol. 2020; 16(4): 680–92. doi: 10.1007/s12024-020-00291-8

16. Smith J, Costello M, Villaseñor R. Investigation Report and Recommendations, City of Aurora, Colorado. Published February 22, 2021.

17. Jones J. 3 ex-cops charged in George Floyd’s death try to blame ‘excited delirium’ as the cause. MSNBC. Published January 28, 2022. www.msnbc.com/the-reidout/reidout-blog/george-floyd-excited-delirium-rcna13990

John Erich is senior editor of EMS World. Reach him at jerich@hmpglobal.com.