Trending Topics

5 keys for responding to excited delirium patients

Incident videos help responders identify the physical and behavioral cues of a severe behavioral emergency that may or may not have a criminal component


Since sudden death is unpredictable, it’s important for police and EMS to act quickly to identify and treat excited delirium syndrome.

Photo/Getty Images

Police response to acute behavioral disturbances, including excited delirium, is a significant challenge to the safety of both officers and suspects. It requires rapid recognition and coordinated response from police and EMS personnel to assess, restrain and sedate the person.

Chief Fred J. Farris used incident narratives, dashcam video and bodycam video to describe the signs and symptoms of excited delirium syndrome (ExDS) and discuss police and EMS response during an educational presentation at the National Tactical Officers Association conference in Milwaukee, Wisonsin.

Farris, a course developer for the NTOA and International Association of Chiefs of Police (IACP), began with a historical overview of excited delirium and definition of the problem. According to Farris, excited delirium is “a state of extreme excitation, commonly associated with illicit drug use and manifested by behavioral and physical changes that may result in sudden and unexplained death.”

Throughout the presentation, Farris engaged attendees to discuss the physical and behavioral cues of the people in the videos, the signs and symptoms of ExDS and the importance of a coordinated law enforcement and EMS response.

“You know it when you see it”

Farris gave an information-rich presentation. Here are several memorable quotes.

  • “What is excited delirium? You know it when you see it, but you might not actually be able to put a definition to it.”
  • “We don’t always know what trips people. We see a sudden behavior change that spirals out of control.”
  • “When the…fight or struggle doesn’t change after the person is in restraint, that is a huge red flag. If they are not calming down, pay attention – there are other things going on.”

Here’s what to know about ExDS

ExDS can lead to sudden death. Since sudden death is unpredictable, it’s important to take actions to quickly end excited delirium syndrome. Four actions – identify, control, sedate and transport – may decrease the chances of sudden death. Here are five key takeaways from Farris’s presentation at NTOA.

1. Know the signs and symptoms of acute excited delirium syndrome

To recognize ExDS police officers and EMS personnel need to know the common symptoms, which include:

  • Sudden onset of symptoms
  • Delirium
  • Extreme agitation
  • Violence with no compliance to overwhelming force
  • Need for physical restraint

These symptoms have a variety of causes, including metabolic, pharmacological, infectious and psychological. During the incident, the cause doesn’t matter. Police and EMS need to recognize the emergency and act – from a physiological perspective, this is an acute medical emergency.

Other ExDS behaviors Farris described were incoherent speech, paranoia, the “thousand-yard stare” and a struggle against restraint without a goal to escape the restraint specifically. Other worrisome signs include rapid breathing, dilated pupils, profuse sweating, hyperthermia, skin discoloration, uncontrollable shaking and respiratory distress.

2. Recognition begins with the 9-1-1 call

Call-takers, recognizing red flags of ExDS, should simultaneously dispatch law enforcement and EMS responders. Once on scene responders should observe the actions of the suspect. Farris encouraged attendees to watch the suspect and ask, “Is the suspect fighting with the cops, or is the suspect fighting to escape?”

“Wherever they are, that isn’t where they want to be, and they don’t know where they want to go,” Farris said. “If you suspect it (ExDS), make sure everyone on scene is aware.”

3. Overwhelming force may be needed to restrain

Once responders decide to go hands-on to restrain the person, Farris instructed attendees to have a plan using multiple officers with assigned roles to get the suspect under control and restrained as quickly as possible. As the videos aptly showed, restraint is rarely easy.

A coordinated response, with a supervisor directing the actions of responders with clear next steps, is important to successful restraint. Once the suspect is restrained, position them to facilitate breathing and airway protection. Continue restraint while medical personnel sedate the patient.

4. Breathing is primal

Farris explained if the suspect or patient is telling us they can’t breathe, responders need to pay attention. Because “breathing is primal” and “respiratory arrest is a prelude to cardiac arrest,” any complaint of difficulty breathing needs to be taken seriously.

Once the suspect is restrained, continuously monitor their breathing and airway patency. Immediately assess the patient if they suddenly become quiet. Manage the patient’s airway and breathing with the tools and training you have. If the patient becomes unresponsive and pulseless, begin chest compressions and apply an AED.

5. Keep learning to better understand ExDS

Farris used videos to discuss the physical and behavioral cues of ExDS. The goal of the videos wasn’t to armchair-quarterback the responders or make light of the bizarre behavior and severity of the condition; instead, videos helped attendees better understand the severity of ExDS and its range of patient presentations and explore the gray area between medical emergency and criminal activity.

There is a lot to learn from these videos of ExDS signs and symptoms – what to expect, what to do and not do. Police and EMS trainers must make sure their personnel take away important learning points to inform and guide their response to these complex and often dangerous emergencies.

Learn more about excited delirium syndrome

To learn more about ExDS, read, listen to or watch this content from Police1, EMS1 and Lexipol.




Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.