Excited Delirium is N-O-T A C-R-I-M-E

 

Penn Tactical Editorial Note

This article is provided by a guest contributor and reflects operational perspectives from the field.

Terminology, definitions, and best practices related to conditions often described as “excited delirium” continue to evolve across both medical and law enforcement communities. This content is intended to support recognition, situational awareness, and coordination with medical resources, not to establish a medical diagnosis.

As with all field response, local protocols, medical direction, and agency policies should guide decision-making.

---

2020 has been an unprecedented year in a multitude of areas when it comes to law enforcement.

In this article, we are going to explore the topic of excited delirium. This subject has come up in several recent high-profile cases, so it is important to understand what excited delirium is, what it is not, and how to best recognize and respond to it at the law enforcement level.

What Excited Delirium Is

Firstly, it is important to recognize that excited delirium is not classified as a disease.

Excited delirium is recognized as a condition by the American Medical Association as well as the American College of Emergency Physicians.

A commonly accepted definition describes it as:

A state of extreme mental and physiological excitement characterized by agitation, hyperthermia, hostility, exceptional strength, and endurance without apparent fatigue.

This aligns with a simple rule often seen in emergency medicine:

Most of what we deal with at the street level is common sense.

Chances are you have either responded to this type of emergency or heard about it.

How to Recognize It

A useful mnemonic to identify excited delirium is:

N-O-T A C-R-I-M-E

• N – Naked (removing clothing and/or sweating heavily)

• O – Objects (violent behavior toward objects, especially glass or reflective surfaces)

• T – Tough (apparent superhuman strength and insensitivity to pain)

• A – Acute (sudden onset, often described as the person “just snapped”)

• C – Confused (disoriented to person, place, or situation)

• R – Resistant (refuses or is unable to follow commands)

• I – Incoherent (shouting or nonsensical speech)

• M – Mental health history (known or suspected history)

• E – Early request for resources (EMS, backup, supervisor, and ideally a CIT-trained officer)

What Causes It

Excited delirium is often associated with illicit drug use, but drug use is only one possible cause.

Other contributing factors include:

• Mental illness

• Chemical imbalances in the brain

• Hyperthermia (heat-related illness)

• Substance withdrawal

• Other underlying medical conditions

It is essential to understand that individuals in this state are experiencing a dangerous medical emergency.

What Is Happening in the Body

To understand excited delirium, it is important to understand what is happening physiologically.

The body maintains a very tight acid-base balance. During an excited delirium event, the body develops metabolic acidosis.

In practical terms, the body is producing more acid than it can manage.

A helpful comparison is intense physical exertion. During extreme exercise, muscles produce lactic acid and breathing increases to compensate.

Now apply that across nearly the entire body at once.

The person is:

• Generating excessive heat

• Releasing large amounts of lactic acid

• Breathing rapidly in an attempt to compensate

The problem is that the body cannot keep up.

Air may be moving in and out, but effective oxygen exchange is failing.

Why “I Can’t Breathe” Matters

This is a critical concept.

In excited delirium, when a person says they cannot breathe, it is not always due to airway obstruction.

Ventilation may be occurring, but respiration is failing.

The body is no longer able to balance oxygen and carbon dioxide effectively.

This is a life-threatening condition.

What Makes It Worse

Several common factors can rapidly worsen the situation:

• Intense physical struggle

• Electrical stimulation causing additional muscle contraction

• Prolonged exertion

• Restriction of chest expansion

• Positioning that limits breathing

It is also important to recognize that many individuals in this state are not in peak physical condition and may have significant underlying health issues.

Officer safety and public safety always come first.

However, when the situation allows, response decisions can significantly influence outcomes.

Response Considerations

The following actions can improve outcomes for both the individual and responding officers:

1. Unified response
Early coordination with EMS, backup officers, a supervisor, and a CIT-trained officer is critical.

2. Slow the situation down
These incidents require patience. If possible, maintain distance and avoid unnecessary escalation.

3. Use a single communicator
Designate one officer to communicate calmly and clearly with the individual.

4. Gather information
Obtain medical and mental health history from bystanders when possible.

5. Coordinate with EMS
EMS personnel determine if and what medications are appropriate. Law enforcement supports access and scene safety.

6. Plan any physical intervention
If a takedown is necessary, it should be coordinated with EMS to allow rapid medical intervention.

7. Prioritize positioning after control
Ensure the individual’s chest and abdomen are not restricted to allow adequate breathing.

8. Initiate cooling if needed
If EMS is delayed, begin cooling measures such as applying ice packs to the neck, groin, and armpits.

The Takeaway

Excited delirium remains a complex and often debated topic.

What is not debated is that it represents a serious medical emergency.

Recognition, coordination, and an understanding of the underlying physiology are critical to improving outcomes.

---

Special thanks to Dr. Bill Worden for his contributions to this discussion.

---

Penn Tactical Editorial Note

Excited delirium remains a complex and debated topic within both medicine and law enforcement.

Regardless of terminology, the critical takeaway is consistent: individuals presenting with extreme agitation, altered mental status, and physiological distress require rapid recognition, coordinated response, and early involvement of EMS.

Penn Tactical Solutions emphasizes practical, evidence-informed training focused on improving outcomes through early identification, controlled response, and prioritization of patient physiology.

---