514 – Excited Delirium

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I. Purpose

The purpose of this policy is to provide guidance and direction in the handling of individuals who appear to be in a state of excited delirium (ExDS), a serious and potentially deadly medical condition involving psychotic behavior, elevated temperature, and an extreme fight-or-flight response by the nervous system. Failure to recognize the symptoms and involve emergency medical services (EMS) to provide appropriate medical treatment may lead to death. Fatality rates of up to 10 percent in ExDS cases have been reported.

II. Policy

It is the policy of the Harris County Sheriff’s Office (HCSO) to identify a subject who displays symptoms of ExDS and attempt to de-escalate the situation safely and consistently, ensure the subject receives a response that is appropriate for his or her needs and to protect the safety of all concerned through the use of mental health and crisis intervention training.

A. ExDS subjects typically are males around the ages of 30 and 40. Most have a history of psychostimulant use or mental illness or a combination of both.

1. Subjects are usually violent and combative with hallucinations, paranoia, or fear.

2. Subjects may demonstrate profound levels of strength, resist painful stimuli or physical restraint, and seem impervious to self-inflicted injuries.

3. Severe sweating is a clue that the subject has an elevated temperature and when combined with hallucinations ExDS should always be promptly considered as a possibility.

NOTE: Differentiating ExDS from other medical causes or uncomplicated intoxication can prove difficult, but a prudent course of action is to assume the worst and obtain medical help for the subject.

B. In cases where death occurs, the following series of events almost always occurs:

1. The subject shows signs of ExDS and is under the influence of drugs or has a history of mental illness.

2. There is a struggle with law enforcement/detentions personnel.

3. Some sort of force is used (physical, chemical, or electronic).

4. The subject is restrained.

5. The subject stops struggling, his or her breathing becomes shallow, and within minutes he or she is dead.

C. Only those restraints necessary to control the situation should be used, and the subject should be positioned in a way that assists breathing, such as on his or her side or sitting up.

D. As soon as the subject is controlled, EMS personnel shall examine the subject and provide medical aid as necessary.

III. Definitions

Excited Delirium Syndrome (ExDS): A medical disorder generally characterized by observable behaviors including extreme mental and physiological excitement, intense agitation, hyperthermia (elevated body temperature) often resulting in nudity, hostility, exceptional strength, endurance without apparent fatigue, and unusual calmness after restraint accompanied by a risk of sudden death.

Positional Asphyxia: Also known as postural asphyxia, positional asphyxia is a form of asphyxia which occurs when someone’s position prevents the person from breathing adequately.

Swarm/Star Technique: A coordinated technique to gain physical control of an individual. This technique requires five personnel. Each deputy/officer is responsible for immobilizing an extremity: head, right arm, left arm, right leg, and left leg. Personnel swarm the subject at the same time immobilizing their assigned extremity.

IV. Procedure

A. Tele-communicators

1. Calls associated with ExDS often include:

a. Descriptions of wild, uncontrollable physical action;

b. Hostility that comes on rapidly;

c. Shedding clothes or nudity;

d. Bizarre and violent behavior;

e. Aggression;

f. Incoherent shouting; or

g. Nonsensical speech and confusion or disorientation.

2. When there is suspicion from the caller that ExDS might be involved, call takers shall request the following types of information:

a. Specific behaviors of the subject.

b. Whether the subject has been or is using PCP, methamphetamine, cocaine, alcohol, or other mind-altering substances.

c. Whether the subject has a history of mental illness or physical illness or substance use.

3. When information suggests ExDS, a sufficient number of deputies to physically control the subject should be dispatched together with EMS personnel, all of whom should be alerted to the possibility that the call might involve ExDS.

4. A Crisis Intervention Response Team (CIRT) unit should be dispatched if available.

5. If a CIRT unit is not available, a CIT trained deputy should be dispatched.

6. A supervisor should be dispatched to all such calls for service, when reasonably possible.

B. Patrol/Detentions Personnel – Assessment

While personnel cannot diagnose ExDS, they should be cognizant of specific signs and characteristic symptoms. These can include one or more of the following:

1. Constant or near constant physical activity

2. Nakedness/shedding of clothing that might indicate “self-cooling” attempts

3. Elevated body temperature/hot to touch

4. Rapid breathing

5. Profuse sweating

6. Extreme aggression or violence

7. Making unintelligible, animal-like noises

8. Insensitivity to/extreme tolerance of pain

9. Excessive strength (out of proportion)

10. Lack of fatigue despite heavy exertion

11. Screaming and incoherent talk

12. Paranoid or panicked demeanor

13. Attraction to bright lights, loud sounds, glass, or shiny objects

C. Patrol/Detentions Personnel – Control

1. If reasonably possible, wait for adequate backup before making physical contact with the subject. Detentions personnel should call for a jail Crisis Intervention Response Team (CIRT) if available.

2. Call for EMS/medical personnel if not already called/dispatched. Where possible, EMS/medical personnel should be on site when subject control is initiated.

3. When the subject is responsive to verbal commands, only one deputy/officer should approach the subject and employ verbal techniques to help reduce his or her agitation before resorting to the use of force. The deputy/officer should:

a. Not rush toward, become confrontational, verbally challenge, or attempt to intimidate the subject, as he or she may not comprehend or respond positively to these actions and may become more agitated and combative;

b. Remain calm and avoid overacting;

c. Introduce yourself;

d. Indicate a willingness to understand and help;

e. Actively listen;

f. If there is no apparent threat of immediate injury to the subject or others, keep your distance and do not make physical contact with the subject;

g. Ask the subject his or her name and if given use it throughout the conversation/interaction;

h. Speak simply and briefly and move slowly;

i. If possible, remove distractions, upsetting influences, and disruptive people;

j. Be friendly, patient, accepting, and encouraging;

k. Remain firm and professional;

l. Reassure the subject that no harm is intended;

m. Recognize that a subject’s delusions or hallucinations are real to him or her.

4. If it is necessary to get the subject under physical control, the Swarm/Star technique is recommended as long as an adequate number of deputies/officers are available. A coordinated restraint plan should be devised before implementing this approach.

5. Deputies/officers should use only those approved restraints that appear necessary to control the situation and only for the period of time required.

6. When restrained, deputies/officers should position the subject in a manner that will assist breathing, such as placement on his or her side, and avoid pressure to the chest, neck or head.

7. Deputies/officers should not attempt to control continued resistance or exertion by pinning the subject to the ground or against a solid object, using their body weight.

8. If possible, do not kneel or sit on the subject’s back or neck while the subject is in a prone position on his or her stomach. This can cause positional asphyxia.

9. Deputies/officers shall check the subject’s pulse and respiration on a continuous basis until transferred to EMS/medical personnel.

10. Following a struggle, the subject should be showing normal signs of physical exertion such as heavy breathing.

NOTE: If the subject becomes calm and breathing is not labored during or after the application of restraints, it might be an indication that he or she is in jeopardy and requires immediate medical attention.

D. Emergency Medical Response

As soon as control is obtained, pre-staged EMS/medical personnel should examine the subject and provide emergency medical aid as necessary.

E. Documentation – Critical for purposes of:

1. Post-incident personnel review and debriefing

2. Training

3. The creation of a historical record to respond effectively to any civil litigation that might arise

4. To respond effectively to inquiries concerning the incident from the community and media

F. Documentation – Personnel shall follow standard incident documentation procedures and ensure the following items, at a minimum, are included.

1. Conditions at the incident scene

2. Description of the subject’s behavior and its duration

3. Description of what the subject said during the event

4. Type of and duration of resistance

5. Actions taken to control the subject

6. Restraints used on the subject and the length of time applied

7. Location of the restraints on the subject

8. Response time and actions taken by EMS/medical personnel, including a list of drugs given to the subject

9. Means of transport and total elapsed time of transport

10. Behavior of subject during transport

11. Means of resuscitation, if applicable

12. Vital signs, especially body temperature

13. Ambient temperature at the time of the incident

14. Results of tests and medical assessments taken by EMS/medical personnel

15. Results of autopsy, if appropriate

16. Any video footage

V. Less-Lethal Options

Deputies and detention officers should be aware that pepper spray, impact weapons, and conducted electrical weapons (CEWs) used in “contact” mode may not always be effective with these subjects due to their elevated threshold of pain.  However, these options should be utilized as part of the use-of-force continuum when it is reasonable to do so.

VI. Training

Training is the foundation of all we do regarding mental health in the agency. The professionalism, mission, and values of an agency are directly related to, and are affected by training. The agency provides the following training to ensure all personnel are prepared for incidents involving excited delirium.

A. Video for All Personnel: All personnel are required to view an agency-produced video explaining the elements and concerns of excited delirium and the strategies for responding to individuals in this state.

B. 8-Hour Mental Health Training for Tele-communications Personnel: All tele-communications personnel receive an 8-hour class on mental health. The training includes a module on excited delirium.

C. 40-Hour Crisis Intervention Training (TCOLE Course #1850): All new hire personnel receive this course. It includes a module on excited delirium.


This policy has been revised on the below listed dates:

March 9, 2020

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