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Date: April 25, 2023

Reference: Walsh et al. Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023

Dr. Brooks Walsh

Guest Skeptic: Dr. Brooks Walsh is a former paramedic, and is currently an emergency physician in the Bridgeport Hospital, Yale-New Haven Health in Connecticut.

This is an SGEM Xtra episode. Brooks reached out to me recently to see if we could revisit the issue of excited delirium. We had done a show on the topic five years ago on SGEM#218. At that time, we recognized there was no universally accepted definition of excited delirium. Please have a listen to the SGEM podcast to hear Brooks discuss the history of this issue and his recent publication.

The American College of Emergency Physicians (ACEP) defined the term in 2009 as “acute delirium (not linked to dementia or preexisting pathologies) associated with extreme physical and psychomotor agitation”.

The history of this issue goes back almost 200 years. Dr. Luther Bell described extreme agitation observed while he was the superintendent of the McLean Asylum for the Insane. The condition was named “Bell’s Mania” when published in the American Journal of Insanity (now American Journal of Psychiatry) in October, 1849 [1].

The term excited delirium syndrome (ExDS) was coined in the 1980s, after a flurry of deaths of individuals in custody or during arrests following extreme agitation [2]. ExDS usually involved men in their 30s after cocaine, methamphetamine, or ecstasy abuse [3-5].

Fast forward to 2008 when an ACEP resolution called for a group to study “excited delirium,” and to disseminate the paper to Emergency Medical Services (EMS) and law enforcement. The task force came up with a paper that was presented and accepted by the ACEP board in 2009. It was never published in a peer reviewed journal but it has been widely disseminated and cited.

There is increasing awareness of the evidence that black men receive the diagnosis of ExDS more often than White men. Those black men who are labeled as having ExDS have a higher mortality than white men. Most recently, a report released by Physicians for Human Rights in March 2022 highlighted these concerns, attracting coverage from national new media.

In emergency medicine, we try to be the physician who will treat anyone for anything at any time (hopefully without judgment). There has been an increased recognition of implicit and explicit biases in the house of medicine. This includes but is not limited to race, gender, age, and socioeconomic status.

ACEP has made the equitable treatment of patients a priority, including recognition of the role that implicit bias exerts in EM [6]. A statement from ACEP described the death of George Floyd as a manifestation of a “public health emergency,” [7] and affirmed that “ACEP’s mission includes the promotion of health equity within the communities we serve.”

Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias?

This brings us to the 2022 article called Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023

There were five key points raised in the article:

  1. Continuing lack of a clear definition for excited delirium
  2. Excited delirium is a health issue
  3. Excited delirium Is a health equity issue
  4. Racialized criteria for diagnosis
  5. “Just semantics?”

Four actions were suggested in the article:

  1. Emergency medicine should avoid the concept of “excited delirium”
  2. Clinicians Should Use Established Medical Diagnoses
  3. ACEP Should “Retire” the 2009 Report
  4. Consider Greater Professional and Racial Diversity in Future Panels

ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings 2021

ACEP published a task force report in April 2021 on Hyperactive Delirium with Severe Agitation in Emergency Settings. It said that “explicit discussion of ‘Excited Delirium Syndrome’ will only occur in the context of evidence surrounding its existence as a distinct pathophysiologic phenomenon”.

It went on to say; “While the authors of this paper were informed by the 2009 paper, this work is de novo and not to be construed as an update or refutation of the 2009 paper”.

National Association of Medical Examiners (NAME) 2023

NAME came out with a statement on this issue in March 2023.

“Although the terms “Excited Delirium” or “Excited Delirium Syndrome” have been used by forensic pathologists as a cause of death in the past, these terms are not endorsed by NAME or recognized in renewed classifications of the WHO, ICD-10, and DSM-V. Instead, NAME endorses that the underlying cause, natural or unnatural (to include trauma), for the delirious state be determined (if possible) and used for death certification.”

There was also a recent CBC story titled: Canadian coroners starting to reject excited delirium as cause of police-related deaths.

ACEP Position Statement On Hyperactive Delirium 2023

Dr. Jeffrey Goodloe

We have some other exciting news. ACEP has come out with a new position on the issue of Hyperactive Delirium in April 2023. In this document they explicitly state that “ACEP does not recognize the use of the term ‘excited delirium’ and its use in clinical settings.” 

Please listen to the podcast to hear Dr. Jeffrey Goodloe who was the senior author on the 2021 task force publication discuss this new hyperactive delirium position statement on the SGEM podcast or click on this LINK.

“The American College of Emergency Physicians (ACEP) recognizes the existence of hyperactive delirium syndrome with severe agitation, a potentially life-threatening clinical condition characterized by a combination of vital sign abnormalities (e.g., elevated temperature and blood pressure), pronounced agitation, altered mental status, and metabolic derangements.1

Emergency physicians and appropriately trained and supervised paramedics most often encounter patients with life-threatening levels of severe agitation and are able to appropriately recognize and treat hyperactive delirium syndrome. These patients are at high risk of direct physical trauma, not only unintentional harm from trauma such as falls, but also the metabolic stress that may result from physical restraint that may be required to facilitate the safety of the patient, bystanders, and responding professionals and ensure appropriate patient evaluation by emergency personnel. ACEP believes there is value in strengthening the training and working relationship between emergency medical services, clinicians, and law enforcement professionals. The goal when treating patients with signs of hyperactive delirium syndrome is to focus on reducing stress, preventing physical harm and transporting them to an emergency department, where they can be treated by an emergency physician. 

ACEP does not recognize the use of the term “excited delirium” and its use in clinical settings.

In order to develop a more medically accurate understanding and description of this clinical syndrome, a 2021 ACEP task force synthesized the most current information available regarding the recognition, evaluation, and management of patients in the prehospital or emergency department setting presenting with hyperactive delirium accompanied by severe agitation. This report was approved by the ACEP Board of Directors and is available at this LINK.

ACEP supports continued multi-disciplinary research, dialogue, and consensus to better recognize, manage, and advocate for patients who show signs of hyperactive delirium accompanied by severe agitation using evidence based, safe care. Any such multi-disciplinary work on this topic should include emergency medicine physicians as well as other stakeholders with diverse backgrounds and expertise in EMS, toxicology, neurology, emergency psychiatry, law enforcement and health equity. Improving the recognition and management of patients with hyperactive delirium syndrome with severe agitation can help prevent avoidable tragedies, enhance training, and encourage best practices and evidence-based medical care.”

Dr. Christopher Kang

We also have the President of ACEP, Dr. Christopher S. Kang, who  is an emergency physician at Madigan Army Medical Center in Tacoma, Wash., and for Olympia Emergency Physicians, LLC, at Providence St. Peter Hospital. He also serves on the faculty of the hospital’s emergency medicine residency program.

You can hear Dr. Kang’s comments on the new ACEP hyperactive delirium position statement on the SGEM podcast or by clicking on this LINK.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based upon the best evidence.

Keener Contest: Last weeks’ winner was Dr. Cindy Bitter. She knew the first Veterans Affairs hospital opened in 1866 to care for veterans of the Civil War. It was called the National Home and was located outside of Augusta, Maine.

Listen to the SGEM podcast to hear this weeks’ question. If you know the answer, send an email to TheSGEM@gmail.com. The first correct answer will receive a cool skeptical prize.

REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

References:

  1. Bell LV. On a form of disease resembling some advanced stages of mania and fever, but so contradistinguished from any ordinary observed or described combination of symptoms as to render it probable that it may be overlooked and hitherto unrecorded malady. Am J Insanity 1849;6.
  2. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci 1985;30:873–80.
  3. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med 2001;19:187–91.
  4. 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;42:25–31.
  5. O’Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol 1993;14:289–95.
  6. ACEP. Non-Discrimination and Harassment Policy Statement. 2021. Available at: https://www.acep.org/patient-care/policy-statements/ non-discrimination-and-harassment/. Accessed August 24, 2022.
  7. ACEP. 5-30-20 ACEP Statement on Structural Racism and Public Health. Available at: http://www.emergencyphysicians.org/pressreleases/ 2020/5-30-20-acep-statement-on-structural-racism-andpublic-health. Accessed December 25, 2020.