Agitated Delirium: A Primer for EMS/Law-Enforcement Personnel

The sudden death of anyone is a personal tragedy for that person’s friends and relatives. It also is a complex and difficult issue for the nation’s law-enforcement, EMS (emergency medical services), and correctional-agencies personnel to deal with. Sudden death is defined by the World Health Organization as cardiorespiratory collapse occurring within 24 hours of symptoms. Many U.S. medical authorities, however, have adopted the definition of sudden death as cardiorespiratory collapse occurring within one hour of the onset of symptoms.    

Unfortunately, EMS personnel and/or other first responders usually arrive on the scene, responding to the acute medical problem, with little or no knowledge of when the first symptoms occurred or if there has been a report of bizarre behaviors.     Sudden In-Custody death, a situation fraught with legal and other complications, is broadly defined as “any unintentional death that occurs while a subject is in police custody.”  Such deaths usually take place after a subject has demonstrated bizarre and/or violent behavior, and has been restrained. These deaths, which frequently appear similar in various respects to the sudden deaths of infants, are not a new phenomenon in the United States – some Agitated-Delirium-related sudden deaths, as they are also described, have been documented as early as 1849. Restraint-related deaths have been a concern for some time of both American and British doctors working with the insane, and were explored in detail, in the journal Insanity, in an article written by a Massachusetts doctor, Dr. Luther V. Bell. There were fewer than 200 sudden in-custody deaths reported in the United States in 2004, many of them deemed the result of Agitated Delirium or Excited Delirium. To put those numbers in context, the Florida Department of Law Enforcement reported 1,128 cocaine-related deaths in the year 1998 (the latest year for which complete data is available).    A Sad But Familiar Pattern The scenarios for most in-custody deaths follow a familiar pattern: A 911 call is received reporting an individual exhibiting bizarre behavior.  Police, EMS, and/or correctional   personnel respond to find an incoherent individual, sweating profusely and suffering from such other symptoms as a high body temperature, dilated pupils, and skin discoloration. When confronted, the subject struggles, forcing the first responders to employ force, which may include the use of pepper spray, batons, electronic-control devices, neck holds, and various restraint techniques. Typically, the subject is taken to the ground and restrained, then put into a prone position for transport to a medical facility or jail.  During transport, however, the subject becomes suddenly calm (which is a major indication of an impending problem).  The calm state is followed by unconsciousness, labored shallow breathing, and then death – even if medical intervention has been attempted. In the circumstances described, it frequently happens that the print and broadcast media will magnify the tragedy by the use of such terms as “Another Pepper Spray Death,” “Another Hogtie Death,” or “Another Taser Death” (depending, of course, on which device or restraint had been used). Such headlines are read, collected, and (far too frequently) believed by the decedent’s family and friends, along with members of special-interest groups. Regrettably, many of these people either cannot or will not believe that the person who died did so at least partly as a result of his (or, very rarely, her) negative lifestyle choices (e.g., addiction to alcohol, cocaine, and/or other drugs; a failure to take the neuroleptic medications prescribed; a struggle with police and/or EMS personnel). The end result is that the police, paramedics, and/or hospital personnel are unfairly blamed for causing the death of the person. A Broad Range of Contemporary Theories According to the recently created Institute for the Prevention of In-Custody Deaths (IPICD), an estimated 99 percent of all in-custody deaths involves males, generally between the ages of 35-44. The person is usually involved in a struggle, and the deaths generally follow episodes of bizarre behavior and/or the use of illegal drugs.  Geographic residence does not seem to be a factor in these in-custody sudden deaths. Contemporary theories of in-custody sudden death are too numerous to list here, but the most currently accepted theories include the following:

  1. Positional, postural, restraint, or compression asphyxia (i.e., caused, for example, by prone positioning, hogtie restraints, lateral vascular neck restraint, and/or the overwhelming weight of several officers required to gain control)
  2. Pepper spray-induced
  3. Psychological-induced (psychogenic death, emotional stress)
  4. Pharmacological-induced (drug interaction and/or combinations and/or rapid drug withdrawal).
  5. Physiological: Cardiomyopathy (due to genetics and/or negative lifestyle choices)
  6. Physiological: Metabolic Acidosis (the buildup, during a struggle, of lactate beyond the body’s ability to cope with it, causing the person to exert himself to death)
  7. Physiological: Catecholamine Damage (a heart attack due to epinephrine and dopamine levels)
  8. Environmental (e.g., a drop in barometric pressure)
  9. Electronic control device-induced ventricular fibrillation.
  10. Electronic control device-induced cardiac damage.
  11. Firearms.
  12. Impact weapons (batons, bean bags, etc.)
  13. Restraint exacerbation of drug abuse.


A Multidisciplinary Approach to EMS Education Obviously, law-enforcement, emergency-medical, and correctional personnel all need to develop a higher awareness of the ramifications of sudden in-custody deaths. Until recently, however, little information has been available on this highly publicized phenomenon. The previously mentioned IPICD fills that gap by offering much-needed training in this area. The institute, headquartered in Henderson, Nev., serves as a combined clearinghouse, resource center, and training provider dedicated to providing interested parties with objective, timely, accurate, qualitative, and quantitative information, training, and operational guidance on matters related to the prevention and management of sudden- and in-custody deaths. IPICD President John G. Peters Jr., Ph.D., A. David Berman of Defensive Tactical Institute, Robert R. Pletcher (a retired police chief), and attorneys Teri Himebaugh and Michael A. Brave have combined their several decades of legal, medical, and research experience to develop and present an instructor program on Theentification, Prevention, Management, and Investigation of Sudden In-Custody Deaths.  Their courses, which provide a multidisciplinary approach to educating police, medical, and correctional personnel, are currently offered free of charge to interested agencies.  (Schedule and registration information can be located on the institute’s website, One of the IPICD’s goals is to help implement a paradigm shift in emergency services by training personnel to recognize that events such as those described above are medical emergencies and not always, or necessarily, criminal acts. In fact, a study on this very thesis is currently being conducted by Dr. Jeffrey Ho of Minneapolis, who is reviewing 162 cases of such deaths and seeking to determine the effect of rapid medical intervention on the survivability of persons in the conditions mentioned. Results of his study are scheduled to be presented at two emergency-medical conferences in the fall of 2005. The IPICD course, which focuses on basic education about sudden in-custody deaths, teaches emergency personnel how toentify the behavioral indicators – in both a law- enforcement and correctional setting – of high-risk candidates. Extensive course time is devoted to a discussion, for both law enforcement and medical purposes, of liability theories and to demonstrating how force-continuum issues relate to the seizure of individuals. Action plans for the prevention and/or investigation of a sudden in-custody death also are discussed in detail. It is important to note that the Agitated Delirium/Excited Delirium phenomenon has few if any boundaries. It will be experienced equally by both small and large agencies. The education of front-line personnel in rapidentification of this condition – combined with the education of investigators, medical examiners, and judicial officials as well – may well lead to an improvement in the procedures used for coping with this deadly condition.

Jay Kehoe

Jay Kehoe



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