The clinical features of excited delirium are generally accepted to be the following:

• A state of high mental and physiological arousal.

• Hyperpyrexia associated with sweating.

• Violence, aggression, and hostility.

• Insensitivity to physical pain or to restraint sprays.

In addition to these clinical observable features, there will certainly also be significant physiological and biochemical sequelae, including dehydration, lactic acidosis, and increased catecholamine levels (22). These biochemical and physiological features may be such that they will render the individual at considerable risk from sudden cardiac arrest, and the descriptions of cases of individuals suffering from excited delirium (23) indicates that the sudden death is not uncommon. Shulack (23) also records that: "the end may come so suddenly that the attending psychiatrist is left with a chagrined surprise," and continues: "the puzzlement is intensified after the autopsy generally fails to disclose any findings which could explain the death." More than 50 years after the publication of that paper, it is still true, but the site of the death may have moved from the psychiatric ward to a police station.

The findings noted in by Shulack in 1944 are also repeated today in many cases that have the features of excited delirium, the difference now being that toxicological examination not uncommonly reveals the presence of cocaine or, in a therapeutic environment, neuroleptic drugs and, as a result, it is tempting to relate the cause of death to the presence of the drug or drugs. In the context of restraint associated with death in cases of excited delirium, the presence of injuries to the neck may lead to the conclusion that death resulted from asphyxia, but this interpretation needs careful evaluation.

What is perhaps of greater importance is that in all of the cases described in the clinical literature (19,20,23-25), there has been a prolonged period of increasingly bizarre and aggressive behavior, often lasting days or weeks before admission to hospital and subsequent death. The clinical evidence available for the deaths associated with police restraint indicates that although there may have been a period of disturbed behavior before restraint and death, the duration of the period will have been measured in hours and not days. This change in time scale may result from the different etiology of the cases of excited delirium now seen, and it is possible that the "natural" and the "cocaine-induced" types of excited delirium will have different time spans but a common final pathway. This feature also must be elucidated in the future.

The conclusion that can be reached concerning individuals displaying the symptoms of excited delirium is that they clearly constitute a medical emergency. The police need to be aware of the symptoms of excited delirium and to understand that attempts at restraint are potentially dangerous and that forceful restraint should only be undertaken in circumstances where the individual is a serious risk to himself or herself or to other members of the public.

Ideally, a person displaying these symptoms should be contained and a forensic physician should be called to examine him or her and to offer advice to the police at the scene. The possibility that the individual should be treated in situ by an emergency psychiatric team with resuscitation equipment and staff available needs to be discussed with the police, and, if such an emergency psychiatric team exists, this is probably the best and safest option. If such a team does not exist, then the individual will need to be restrained with as much care as possible and taken to the hospital emergency room for a full medical and psychiatric evaluation. These individuals should not be taken directly to a psychiatric unit where resuscitation skills and equipment may not be adequate.

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