ReviewDeaths in custody: Are some due to electronic control devices (including TASER® devices) or excited delirium?
Introduction
An “electronic control device” (ECD) is an operator-controlled apparatus that transmits short electric pulses either through electrodes (from a “stun gun,” as described by Schmiederer et al.),1 or through wires attached to darts (e.g., from a TASER® [“Thomas A. Swift’s Electric Rifle”] ECD [alternatively referred to as an “electric shocking device” or “conducted energy weapon”]) into a subject, causing involuntary muscle contractions that incapacitate. (TASER® is a registered trademark of TASER International, Inc., Scottsdale, Arizona, USA). Denk et al.2 suggested that TASER ECDs can be more effective than other models of similar devices. (For a recent comprehensive review of ECD effects, see Jenkinson et al.3). Tracings of typical waveforms produced by the TASER model “X26” ECD have been presented previously.4, 5
Although the muscle contraction caused by ECD application is not synonymous with conventional muscular exercise, there may be some similarities. Rhabdomyolysis (breakdown of muscle tissue to the extent that contents are liberated into the circulation) may be caused by either excessive muscular activity6 or electrical injury.7 (Other causes are hyperthermia and direct myotoxins.8 One may expect any possible electrical injury due to ECD exposure, however, to be quite different from conventional electrical injury (due to, e.g., 60 Hz alternating current), since electrical properties (most importantly, current flow) of the two modalities are dissimilar. An important point is the amount of power delivered in a given period of time, or energy in joules (watt–seconds) (see Fechner et al.9 for discussion of these factors).
Medical examiners have listed ECDs as a cause of death (see Remsberg 10 for discussion), despite the lack of a clear-cut unifying pathophysiological hypothesis. At the same time, a syndrome often referred to as “excited delirium” (at least in the United States, if not in other countries)11 is one possible explanation of unanticipated deaths of suspects in police custody.12 Ross13 has reviewed factors that have been associated with past cases of deaths in custody presumed to be related to excited delirium.
In news-media accounts of deaths during incidents involving applications of ECDs, the initial focus is often on the devices themselves as the important factor relating to death, with other issues considered to be secondary. The excited delirium syndrome, however, was reported in the literature prior to the development of ECDs currently in use.
The purposes of this paper are to (1) review potential detrimental effects (as reflected in blood factors and physiological measurements) of exposure to ECDs, (2) assess the relative importance of such factors to survival (in comparison with certain aspects of excited delirium), and (3) summarize current opinions regarding the potential role of ECDs versus that of excited delirium during deaths in custody.
Section snippets
Terminology and definitions of excited delirium
Wetli et al.14 and Karch15 have listed four components to be included in a definition of the excited delirium syndrome: delirium with agitation, respiratory arrest, hyperthermia, and death. One of the first uses of the specific term “excited delirium” was by Wetli and Fishbain16 (although “cocaine-induced delirium” had been described before that time). That particular first use of the term was descriptive of behavior, rather than a diagnosis. The syndrome was earlier described under various
Overview
Some of the factors mentioned in the following sections are interrelated, but are listed separately for discussion purposes. It would be unethical to apply extreme (i.e., long-duration or repeated) exposures of ECDs, which may cause harm or death, to human subjects. Therefore, some of the data discussed in this review are from studies of animals.
The first study of blood factors after any type of ECD exposure was performed by Jauchem et al.)30 The swine as an animal model was selected for
Confounding factors that may be present during ECD application and cases of excited delirium
Active physical restraint and drug use are confounding factors that may occur during incidents involving either applications of ECDs or excited delirium. Law-enforcement personnel may utilize a “prone maximal restraint position”85 to control combative subjects. In a series of 21 cases of death associated with excited delirium,86 all of the subjects had undergone restraint. Chan et al.87 concluded that such a position resulted in a “restrictive pulmonary function pattern,” but with no evidence
Suggestions by other investigators for use of ECDs when excited delirium may be present
The use of ECDs in mental health settings (with individuals experiencing a crisis) is controversial.109 Some investigators have recommended enactment of policies prohibiting the “knowing use” of ECDs on mentally ill individuals (e.g., Stanford Criminal Justice Center).110 Ho et al.,111 however, found that, in nearly half of the cases in one study population, an ECD “was used in place of a firearm even though the law-enforcement use of deadly force would have been authorized and justified in
Concluding remarks
Primary effects of factors coincident with ECD exposure events may, by themselves, be more harmful than effects of limited ECD applications. Many victims of drug-induced excited delirium die without the application of any specific law-enforcement techniques.14 Stone113 noted that, on the basis of medical evidence, ECDs are not “the causes, in and of themselves,” of sudden deaths in custody.
Some investigators have suggested that any description of ECD applications as “the last straw” or “being
Conflict of interest
The author has not had any relationship with any manufacturers of electronic control devices, including employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.
Acknowledgements
This review was supported by the Directed Energy Research Programs Department, National Institute of Justice, Office of Justice Programs, United States Department of Justice.
The views and opinions expressed in this article are the author’s own and do not necessarily state or reflect those of the US Government.
References (116)
- et al.
The relative risk of police use-of-force options: evaluating the potential for deployment of electronic weaponry
J Clin Forensic Med
(2006) - et al.
Blood factors of Sus scrofa following a series of three TASER® electronic control device exposures
Forensic Sci Int
(2008) - et al.
The other medical causes of rhabdomyolysis
Am J Med Sci
(2003) - et al.
Factors associated with sudden death of individuals requiring restraint for excited delirium
Am J Emerg Med
(2001) - et al.
Cocaine-associated agitated delirium and the neuroleptic malignant syndrome
Am J Emerg Med
(1996) - et al.
Acidosis, lactate, electrolytes, muscle enzymes, and other factors in the blood of Sus scrofa following repeated TASER® exposures
Forensic Sci Int
(2006) Electronic control devices and the clinical milieu. Reply
J Am Coll Cardiol
(2007)- et al.
Severe hyperkalemia with minimal electrocardiographic manifestations: A report of seven cases
J Electrocardiol
(1999) Rhabdomyolysis and drugs of abuse
J Emerg Med
(2000)- et al.
Incidence of cocaine-associated rhabdomyolysis
Ann Emerg Med
(1991)
Cardiac electrophysiological consequences of neuromuscular incapacitating device discharges
J Am Coll Cardiol
Electronic control devices and the clinical milieu
J Am Coll Cardiol
Cardiopulmonary effects of a xylazine and ketamine combination in pigs
Res Vet Sci
Anesthetic regimen effects on a pediatric porcine model of asphyxial arrest
Resuscitation
Cocaine and the heart
Hum Pathol
Myocardial disarray: An architectural disorganization linked with adrenergic stress?
Int J Cardiol
15-Second conducted electrical weapon exposure does not cause core temperature elevation in non-environmentally stressed resting adults
Forensic Sci Int
The physiologic effects of a conducted electrical weapon in swine
Ann Emerg Med
Evaluation of myocardial injury following repeated internal atrial shocks by monitoring serum cardiac troponin I levels
Chest
Withdrawal of Taser electroshock devices: Too much, too soon
Ann Emerg Med
Prevalence of rhabdomyolysis in drug deaths
Forensic Sci Int
Electronic gun (Taser®) injuries
Ann Emerg Med
Severe metabolic acidosis secondary to exertional hyperlactemia
Am J Emerg Med
Acute respiratory and metabolic acidosis induced by excessive muscle contraction during spinal evoked stimulation
Br J Anaesth
Positional asphyxia: inadequate oxygen, or inadequate theory? [Letter]
Forensic Sci Int
Sudden death in individuals in hobble restraints during paramedic transport
Ann Emerg Med
Does ethanol enhance cocaine toxicity?
J Clin Forensic Med
Severe hyperlactemia and metabolic acidosis following cocaine use and exertion
Am J Emerg Med
Specific traces in stun gun deployment
Int J Legal Med
Rhabdomyolysis
Am Fam Physician
Rhabdomyolysis caused by electric injury
J Emerg Med
Herzstromdichte als wichtigster biologischer Parameter bei Stromexposition in der Badewanne [Heart current density as the most important biological parameter of electrocution in the bathtub]
Beitr Gerichtl Med
Behind the excited delirium headlines
J Emerg Med Serv News
Tödliche Zwischenfälle bei der Festnahme höchstgradig erregter Personen [Fatal incidences during arrest of highly agitated persons]
Arch Kriminol
Factors associated with excited delirium deaths in police custody
Mod Pathol
Cocaine-induced psychosis and sudden death in recreational cocaine users
J Forensic Sci
Lethal catatonia
Am J Psychiat
Handbook of forensic pathology
Beyond the basics: endocrine emergencies. Part 1: Hyperthyroidism and thyroid storm
Emerg Med Serv
The scene of death and the autopsy
Excited delirium: Does it exist?
Perspect Psychiatr Care
Excited delirium
WHO basic classification in forensic medicine
Beitr Gerichtl Med
Cited by (47)
Special topics: in-custody deaths, physical altercations, neglect (adult), approach to unexpected hemorrhage, and delayed and concealed homicides
2022, Principles of Forensic Pathology: From Investigation to CertificationApproach to environmental deaths
2022, Principles of Forensic Pathology: From Investigation to CertificationA TASER conducted electrical weapon with cardiac biomonitoring capability: Proof of concept and initial human trial
2016, Journal of Forensic and Legal MedicineCitation Excerpt :However, isolated case reports of deaths occurring shortly after CEW use leave lingering questions of cardiac safety.3–5 These unexpected deaths after exposure to a CEW discharge remain rare, and are often intertwined with other risk factors for sudden death including exertion, drug use, and pre-existing medical conditions.6–8 A CEW delivers a series of low current, high voltage electrical impulses via two insulated wires attached to probes, which are propelled through the air and imbed themselves in a subject's skin or clothing.9
Police use of TASER devices in mental health emergencies: A review
2014, International Journal of Law and PsychiatryCitation Excerpt :The warning includes “excited delirium”, a diagnostic category not found in either of the commonly used diagnostic taxonomies, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM IVTR) or the World Health Organization's International Classification of Diseases (ICD-9) (Takeuchi, Ahern, & Henderson, 2011), but which is used to describe a syndrome in which people experience severe agitation with lethal consequences (Vilke, Bozeman, Dawes, Demers, & Wilson, 2012). Excited delirium is commonly cited as contributing to deaths when individuals have been subject to TASER device discharge (Jauchem, 2010; Strote & Hutson, 2006). Use of TASER devices in mental health emergencies has also been subject of debate, with rights groups such as Amnesty International criticising use of TASER devices on people with mental illness.
Safety of transcardiac conducted electrical weapon probe deployments remains unclear
2014, Journal of Emergency MedicineCare of the Patient in Excited Delirium
2013, Journal of Emergency NursingCitation Excerpt :Recycling of the PCP already in the body results in fluctuating levels of intoxication. The dangers of restraints were first recognized when violently agitated people died unexpectedly while in police custody.3 Between 2003 and 2005, 1095 arrest-related deaths associated with excited delirium occurred in 47 states and the District of Columbia.19