Page 3 - Newsletter March 2020

Page 3 NEWSLETTER

Excited delirium syndrome

Dr. Ajith Rathnaweera

Department of Forensic Medicine, Faculty of Medicine, University of Ruhuna, Galle

The police tried arresting a 37 year-old male, after the symptoms associated with this condition are
receiving several complains of aggressive behaviour explainable, cause of death is not very straight
and shouting at his neighbours. At the sight of the forward. The uncommon nature of the syndrome
police, he initially tried to run, however he was adds to the outrage and strengthens the claim of
cornered by the attending officers. At that moment, police brutality. Some people believe that excited
he became very aggressive and violent and threat- delirium is a cover used by the authorities in cases
ened the police officers. He even grabbed one officer of excessive use of force by the law enforcement
and was able to put him down. The police officers agencies .
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had to wrestle with him for almost five minutes In most instances, just like the above mentioned
before they were able to control him. According to one, deaths are due to combined effects of physio-
them he had enormous strength and was very agitat- logical consequences of violent physical activity
ed at that time. Once he was hand cuffed, he became and the effect of the drugs they were on. During
very silent. He was immediately taken to the police a struggle, there is sudden release of catechola-
station where he was put behind bars. Half an hour mines into the circulation. Catecholamines usually
later, when the inquiring officers came to get a state- increases the rate and force of contraction of
ment from him, he was found to be unresponsive.
the heart, the conduction velocity and the blood
He was immediately taken to the nearby hospital, pressure. All these events leads to an increase
where he was found to be dead on admission. 2
demand of oxygen by the heart . The highest levels
An inquest was held and a post-mortem examination of catecholamine levels are observed not during the
was carried out. There were no significant external struggle but couple of minutes after cessation of
or internal injuries present. Blood alcohol level was such activity . During a struggle, blood potassium
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220 mg/dl and cocaine and its metabolites were concentrations also increases rapidly . It is reported
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identified in his blood and urine samples. Histo- that this increase may be as high as 5 mEq/l
pathology of all organs were performed and there or more. However, just after the struggle, there
was no significant pathology present. Relations of the is rapid drop of potassium levels which ultimately
deceased charged that this person died following reaches hypockalaemic levels. This hypokalaemia
police assault. However, post-mortem examination can persist for around 90 minutes after the strug-
did not reveal any suggestive evidence. The probable gle . These extreme potassium levels have cardiac
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cause of death was given as Excited Delirium. arrythmogenic effects. However, these arrythmo-

From time to time, forensic pathologists will genic effects are neutralized by the simultaneous
encounter cases of sudden death during or immedi- rising levels of chatecholamines, which at initial
ately after a violent struggle, with a followed up levels have a cardio protective action. “Thus,
post-mortem examination failing to reveal an the danger time for arrhythmias is immediately
anatomical cause of death. Usually these deaths are following cessation of physical activity, when
following attempted restrains of a violent struggler blood catecholamine, concentrations continue to
by the law enforcement officers. The usual presen- rise while potassium levels drop dramatically to
tation in such deaths is that of individuals in excited hypokalemic levels. This period has been referred
delirium. Explaining excited delirium to the general
to as the time of post-exercise peril, in that there
public sometimes is very difficult. Even though

Newsletter; Galle Medical Association, March 2020; Volume 20: Issue 1