Appendix A

Excited Delirium Checklist

Excited delirium or excited delirium syndrome is the only one form of poten-

tial sudden death that law enforcement officers may encounter. Other poten-

tial causes of unexpected arrest-related deaths include, but are not limited to:

sudden unexpected death in epilepsy, sickle cell sudden death, and severe heart

disease.

Present? Criterion

911 Call – emergency contact for assistance

1. Critical call phrases include, ‘‘He just freaked out,’’ ‘‘just snapped,’’ ‘‘flippedout,’’ or a person is ‘‘running around naked.’’ [1]

Law enforcement

2. Agitation, screaming, extreme fear response, or panic [2–6]

3. Violence, assault, or aggression towards others [6–9]

4. Suspicion of impending death. Typical comments include, ‘‘I’m dying,’’ ‘‘Pleasesave me,’’ or ‘‘Don’t kill me’’ [10]

5. Incoherence or disorganized speech. Grunting or animal sounds [9,11]

6. Clothing removal inappropriate for ambient temperature or complete nudity[6,12–14].

7. Disorientation or hallucinations [6,15–18]

8. Mania, paranoia, anxiety, or avoidance behavior [2,6,19–22]

9. Constant motion or hyperactivity [2,18,23–25]

Capture, control, and restraint of subject

10. Extreme or ‘‘super human’’ strength [9,21]

11. High threshold of or imperviousness to pain [11,14]

12. Extreme stamina [26,11]

13. Brief quiet period before collapse likely corresponding with respiratory arrest[2,5,11,27]

Emergency medical services contact and intervention

14. Presenting rhythm of PEA (pulseless electrical activity) or asystole[26,28–30]. Also documented by ‘‘No shock advised’’ with automatic externaldefibrillator [30]

433

(continued)

Present? Criterion

Emergency department

15. High core body temperature [3,4,9,19,31,32]

16. Acidosis (acidic blood) [11,33,34]

17. Rhabdomyolysis (if suspect is resuscitated) [3,32,35]

Law enforcement/forensic investigator death investigation

18. History of chronic stimulant abuse or mental illness [2,7,15,20,25,28,36–39].History of violence or drug related arrests, mental health histories andtreatments, and drug rehabilitation interventions, etc.

19. Damage to shiny objects such as glass, mirrors, and lights [11]. Reportedbehaviors may include attacking a squad car light bar or charging oncomingtraffic at night. Occasionally generalized vandalism

Pathologist – medical examiner investigation

20. Minor injuries from fighting against restraints (e.g. handcuffs, hobbles)

21. Positive mash (central nervous system biomarkers) test for dopaminetransporter assay and heat shock protein [3,19,20,40–44]

22. Positive brain and hair toxicology screen for chronic stimulant abuse[40,45–49]. Post-incident drug levels may be low to negative

Contributors: Mark Kroll, PhD; Charles Wetli, MD; Deborah Mash, PhD; Steven Karch,MD; Michael Graham, MD, Jeffrey Ho, MD.Notes: A syndrome is an aggregate of signs and symptoms that define a medical condition.Not all persons with a certain syndrome have all the same signs and symptoms. Not all cases ofa syndrome result from the same cause. For example, some persons with carpal tunnelsyndrome will have numbness and tingling, while others will have weakness and pain. Also,some persons with carpal tunnel syndrome will have it because of trauma, while others willhave the syndrome because of pregnancy, diabetes, rheumatoid arthritis, or thyroid disease.Persons with the excited delirium syndrome will have various combinations of some of thesigns and symptoms listed above. The cause (etiology) of the excited delirium syndrome inany individual may be due to one or more of a number of conditions. The most commonconditions are mental illness and illegal stimulant abuse (especially cocaine and methamphe-tamine) [28].Because the term ‘‘excited delirium syndrome’’ has not been widely used until recent years,many physicians do not recognize the term even though they may be very familiar withagitation and deaths due to drugs and other conditions. It is important to avoid the distractionof the various terms that have been applied to this syndrome. For example, what is nowreferred to as excited delirium [2–4,14,20,21,24,26–28,32–35,38,41,42,50–57] or agitated delir-ium [29,44,58–103] has also been called: Bell’s mania [18], acute exhaustive mania [104], acutedelirious mania [18], delirium grave [18], typhoma [18], acute delirium [18], manic-depressiveexhaustion [12], excited catatonia [77], lethal catatonia [105], and neuroleptic malignantsyndrome [7,14,31,60,105].

References

1. Code 1069ExcitedDeliriumDispatchPolicy. In: Sheriff’s_Office, ed. Jacksonville, FL, 2006.2. Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint

for excited delirium: a retrospective study of deaths in police custody and in the commu-nity. CMAJ 1998;158:1603–7.

434 Excited Delirium Checklist

3. Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, HearnWL, Mash DC. Fatal exciteddelirium following cocaine use: epidemiologic findings provide new evidence for mechan-isms of cocaine toxicity. J Forensic Sci 1997;42:25–31.

4. Blaho K, Winbery S, Park L, Logan B, Karch SB, Barker LA. Cocaine metabolism inhyperthermic patients with excited delirium. J Clin Forensic Med 2000;7:71–6.

5. Stefan H. Sudden death of psychiatric patients following great excitation and exhaustionwhich has no actual anatomic basis. Dtsch Med Wehnschr 1934;60:1550–8.

6. Shulack N. Sudden ‘‘exhaustive’’ death in excited patients. Psychiatr Q 1944;18:3–12.7. Kasantikul D, Kanchanatawan B. Neuroleptic malignant syndrome: a review and report

of six cases. J Med Assoc Thai 2006;89:2155–60.8. Bell L. On a form of disease resembling some advanced stages of mania and fever, but so

contradistinguished from any ordinary observed or described combination of symptomsas to render it probable that it may be overlooked and hitherto unrecorded malady. Am JInsanity 1849;6:97–127.

9. Fishbain DA,Wetli CV. Cocaine intoxication, delirium, and death in a body packer.AnnEmerg Med 1981;10:531–2.

10. Karch S, Kroll M. Unpublished observations of 150 excited delirium cases, 2008.11. Wetli C. Excited delirium. In: Chan R, ed. Sudden Deaths in Custody. Totowa: Humana

Press, 2006:99–112.12. Derby I. Manic-depressive ‘‘exhaustion’’ deaths. Pyschiatric Q 1933;7:436–49.13. Shulack N. Sudden ‘‘exhaustive’’ death in excited patients. Psychiatr Q 1938;12:282–93.14. Ross DL. Factors associated with excited delirium deaths in police custody. Mod Pathol

1998;11:1127–37.15. StagnoD, Gibson C, Breitbart W. The delirium subtypes: a review of prevalence, phenom-

enology, pathophysiology, and treatment response. Palliat Support Care 2004;2:171–9.16. Ross CA, Peyser CE, Shapiro I, Folstein MF. Delirium: phenomenologic and etiologic

subtypes. Int Psychogeriatr 1991;3:135–47.17. DavidsonG. Concerning the cause of death in certain cases.AmJPsychiatry 1934;91:41–9.18. Kraines S. Bell’s mania (acute delirium). Am J Psychiatry 1934;91:29–40.19. Mash DC, Ouyang Q, Pablo J, Basile M, Izenwasser S, Lieberman A, Perrin RJ. Cocaine

abusers have an overexpression of alpha-synuclein in dopamine neurons. J Neurosci2003;23:2564–71.

20. Mash DC, Pablo J, Ouyang Q, HearnWL, Izenwasser S. Dopamine transport function iselevated in cocaine users. J Neurochem 2002;81:292–300.

21. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in recreationalcocaine users. J Forensic Sci 1985;30:873–80.

22. AnglinMD, Burke C, Perrochet B, Stamper E, Dawud-Noursi S. History of the metham-phetamine problem. J Psychoactive Drugs 2000;32:137–41.

23. Schroeder U, Schroeder H, Darius J, Grecksch G, Sabel BA. Simulation of psychosis bycontinuous delivery of phencyclidine from controlled-release polymer implants. BehavBrain Res 1998;97:59–68.

24. Pedal I, Zimmer G, Mattern R, Mittmeyer HJ, Oehmichen M. Fatal incidences duringarrest of highly agitated persons. Arch Kriminol 1999;203:1–9.

25. Fava M. Psychopharmacologic treatment of pathologic aggression. Psychiatr Clin NorthAm 1997;20:427–51.

26. DiMaio T, VJM D. Excited delirium syndrome cause of death and prevention. BocaRaton: Taylor & Francis, 2006.

27. Stratton SJ, Rogers C, Green K. Sudden death in individuals in hobble restraints duringparamedic transport. Ann Emerg Med 1995;25:710–2.

28. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with suddendeath of individuals requiring restraint for excited delirium. Am J Emerg Med2001;19:187–91.

29. ParkKS,Korn CS,Henderson SO.Agitated delirium and sudden death: two case reports.Prehosp Emerg Care 2001;5:214–6.

Excited Delirium Checklist 435

30. Swerdlow C, Kroll M, Williams H, Biria M, Lakkireddy D, Tchou P. Presenting rhythmin sudden custodial deaths after use of TASER1 electronic control device.Heart Rhythm2008;5:S44.

31. Nielsen J, Bruhn AM. Atypical neuroleptic malignant syndrome caused by olanzapine.Acta Psychiatr Scand 2005;112:238–40; discussion 240.

32. Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis andexcited delirium: different stages of the same syndrome. Am J Forensic Med Pathol1999;20:120–7.

33. AllamS,Noble JS. Cocaine-excited deliriumand severe acidosis.Anaesthesia 2001;56:385–6.34. Brice JH, Pirrallo RG, Racht E, Zachariah BS, Krohmer J. Management of the violent

patient. Prehosp Emerg Care 2003;7:48–55.35. Karch SB. Karch’s Pathology of Drug Abuse, CRC Press, Boca Raton, 2002:541.36. DiMaio VJ. Forensic Pathology, CRC Press, Boca Raton, 2001:656.37. Gray SD, Fatovich DM, McCoubrie DL, Daly FF. Amphetamine-related presentations

to an inner-city tertiary emergency department: a prospective evaluation. Med J Aust2007;186:336–9.

38. Morrison A, Sadler D. Death of a psychiatric patient during physical restraint. Exciteddelirium – a case report. Med Sci Law 2001;41:46–50.

39. Pearlson GD. Psychiatric and medical syndromes associated with phencyclidine (PCP)abuse. Johns Hopkins Med J 1981;148:25–33.

40. Stephens BG, Jentzen JM, Karch S, Mash DC, Wetli CV. Criteria for the interpretationof cocaine levels in human biological samples and their relation to the cause of death.Am J Forensic Med Pathol 2004;25:1–10.

41. MashDC, Staley JK.D3 dopamine and kappa opioid receptor alterations in human brainof cocaine-overdose victims. Ann N Y Acad Sci 1999;877:507–22.

42. Mash DC, Staley JK, Izenwasser S, Basile M, Ruttenber AJ. Serotonin transportersupregulate with chronic cocaine use. J Chem Neuroanat 2000;20:271–80.

43. Stephens BG, Jentzen JM, Karch S, Wetli CV, Mash DC. National Association ofMedical Examiners position paper on the certification of cocaine-related deaths. Am JForensic Med Pathol 2004;25:11–3.

44. Chen L, Segal DM, Moraes CT, Mash DC. Dopamine transporter mRNA in autopsystudies of chronic cocaine users. Brain Res Mol Brain Res 1999;73:181–5.

45. Berankova K, Habrdova V, Balikova M, Strejc P. Methamphetamine in hair and inter-pretation of forensic findings in a fatal case. Forensic Sci Int 2005;153:93–7.

46. Kimura H, Mukaida M, Mori A. Detection of stimulants in hair by laser microscopy.J Anal Toxicol 1999;23:577–80.

47. Takayama N, Tanaka S, Hayakawa K. Determination of stimulants in a single humanhair sample by high-performance liquid chromatographic method with chemilumines-cence detection. Biomed Chromatogr 1997;11:25–8.

48. Kintz P, Cirimele V, Tracqui A,Mangin P. Simultaneous determination of amphetamine,methamphetamine, 3,4-methylenedioxyamphetamine and 3,4-methylenedioxymetham-phetamine in human hair by gas chromatography-mass spectrometry. J Chromatogr BBiomed Appl 1995;670:162–6.

49. Nagai T, Kamiyama S, Nagai T. Forensic toxicologic analysis of methamphetamine andamphetamine optical isomers by high performance liquid chromatography. Z Rechtsmed1988;101:151–9.

50. Sztajnkrycer MD, Baez AA. Cocaine, excited delirium and sudden unexpected death.Emerg Med Serv 2005;34:77–81.

51. O’Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J ForensicMed Pathol 1993;14:289–95.

52. Strote J, Range Hutson H. Taser use in restraint-related deaths. Prehosp Emerg Care2006;10:447–50.

53. Paquette M. Excited delirium: does it exist? Perspect Psychiatr Care 2003;39:93–4.

436 Excited Delirium Checklist

54. Gowers WR. A Manual of Diseases of the Nervous System, J&A Churchill, London,1896.

55. Nahas GG, Burks TF, Hollister LE. Drug Abuse in the Decade of the Brain, IOS Press,Amsterdam, 1997:281.

56. Levine B. Principles of Forensic Toxicology, AACC, Washington, DC, 2003:385.57. Karch SB. Drug Abuse Handbook, CRC Press, Boca Raton, FL, 2006:1267.58. Mets B, Jamdar S, Landry D. The role of catecholamines in cocaine toxicity: a model for

cocaine ‘‘sudden death’’. Life Sci 1996;59:2021–31.59. Karch SB, Wetli CV. Agitated delirium versus positional asphyxia. Ann Emerg Med

1995;26:760–1.60. Wetli CV, Mash D, Karch SB. Cocaine-associated agitated delirium and the neuroleptic

malignant syndrome. Am J Emerg Med 1996;14:425–8.61. Mirchandani HG, Rorke LB, Sekula-Perlman A, Hood IC. Cocaine-induced agitated

delirium, forceful struggle, and minor head injury. A further definition of sudden deathduring restraint. Am J Forensic Med Pathol 1994;15:95–9.

62. Irwin P,Murray S, Bilinski A, Chern B, Stafford B. Alcohol withdrawal as an underratedcause of agitated delirium and terminal restlessness in patients with advanced malig-nancy. J Pain Symptom Manage 2005;29:104–8.

63. Morita T, Tei Y, Inoue S. Agitated terminal delirium and association with partial opioidsubstitution and hydration. J Palliat Med 2003;6:557–63.

64. Morita T, Tei Y, Inoue S. Impaired communication capacity and agitated delirium in thefinal week of terminally ill cancer patients: prevalence and identification of research focus.J Pain Symptom Manage 2003;26:827–34.

65. Vatsavayi V, Malhotra S, Franco K. Agitated delirium with posterior cerebral arteryinfarction. J Emerg Med 2003;24:263–6.

66. VilkeGM,ChanTC.Agitated delirium and sudden death.Prehosp Emerg Care 2002;6:259;author reply 259–60.

67. Frye MA, Coudreaut MF, Hakeman SM, Shah BG, Strouse TB, Skotzko CE. Contin-uous droperidol infusion for management of agitated delirium in an intensive care unit.Psychosomatics 1995;36:301–5.

68. Levenson JL. High-dose intravenous haloperidol for agitated delirium following lungtransplantation. Psychosomatics 1995;36:66–8.

69. Sanders KM, Murray GB, Cassem NH. High-dose intravenous haloperidol for agitateddelirium in a cardiac patient on intra-aortic balloon pump. J Clin Psychopharmacol1991;11:146–7.

70. VerslegersW, De Deyn PP, Saerens J, Marien P, Appel B, Pickut BA, Lowenthal A. Slowprogressive bilateral posterior artery infarction presenting as agitated delirium, compli-cated with Anton’s syndrome. Eur Neurol 1991;31:216–9.

71. Mori E, Yamadori A. Acute confusional state and acute agitated delirium. Occurrenceafter infarction in the right middle cerebral artery territory.ArchNeurol 1987;44:1139–43.

72. Julien J, Vital C, Vallat JM, Bourgoin B. Epilepsy and agitated delirium caused by anastrocytoma of the amygdala. Eur Neurol 1979;18:387–90.

73. Medina JL, Chokroverty S, Rubino FA. Syndrome of agitated delirium and visualimpairment: a manifestation of medial temporo-occipital infarction. J Neurol NeurosurgPsychiatry 1977;40:861–4.

74. Medina JL, Rubino FA, Ross E. Agitated delirium caused by infarctions of the hippocam-pal formation and fusiform and lingual gyri: a case report. Neurology 1974;24:1181–3.

75. Horenstein S, ChamberlinW, Conomy J. Infarction of the fusiform and calcarine regions:agitated delirium and hemianopia. Trans Am Neurol Assoc 1967;92:85–9.

76. Spiller JA, Keen JC. Hypoactive delirium: assessing the extent of the problem forinpatient specialist palliative care. Palliat Med 2006;20:17–23.

77. Pruett JR, Rizvi ST. A16-year-old girl with excited catatonia treated with low-dose oralLorazepam. J Child Adolesc Psychopharmacol 2005;15:1005–10.

Excited Delirium Checklist 437

78. Kusne S, Smilack J. Transmission of rabies virus from an organ donor to four transplantrecipients. Liver Transpl 2005;11:1295–7.

79. DuggalMK, SinghA, Arunabh, Lolis JD,GuzikHJ. Olanzapine-induced vasculitis.AmJ Geriatr Pharmacother 2005;3:21–4.

80. Ogasawara K, Komoribayashi N, Kobayashi M, Fukuda T, Inoue T, Yamadate K,Ogawa A. Neural damage caused by cerebral hyperperfusion after arterial bypasssurgery in a patient with moyamoya disease: case report. Neurosurgery 2005;56:E1380;discussion E1380.

81. Srinivasan A, Burton EC, Kuehnert MJ, Rupprecht C, Sutker WL, Ksiazek TG,Paddock CD, Guarner J, Shieh WJ, Goldsmith C, Hanlon CA, Zoretic J, FischbachB, Niezgoda M, El-Feky WH, Orciari L, Sanchez EQ, Likos A, Klintmalm GB, CardoD, LeDuc J, Chamberland ME, Jernigan DB, Zaki SR. Transmission of rabies virusfrom an organ donor to four transplant recipients. N Engl J Med 2005;352:1103–11.

82. Cameron D, Bridge D, Blitz-Lindeque J. Use of sedation to relieve refractory symptomsin dying patients. S Afr Med J 2004;94:445–9.

83. Muller-Busch HC, Andres I, Jehser T. Sedation in palliative care – a critical analysis of7 years experience. BMC Palliat Care 2003;2:2.

84. Cowan JD, Palmer TW. Practical guide to palliative sedation.CurrOncolRep 2002;4:242–9.85. Cheng C, Roemer-Becuwe C, Pereira J.Whenmidazolam fails. J Pain SymptomManage

2002;23:256–65.86. Morita T, Tsunoda J, Inoue S, Chihara S. Terminal sedation for existential distress.

Am J Hosp Palliat Care 2000; 17:189–95.87. Travis SS, Conway J, Daly M, Larsen P. Terminal restlessness in the nursing facility:

assessment, palliation, and symptom management. Geriatr Nurs 2001;22:308–12.88. Chiu TY, Hu WY, Lue BH, Cheng SY, Chen CY. Sedation for refractory symptoms of

terminal cancer patients in Taiwan. J Pain Symptom Manage 2001;21:467–72.89. Ogasawara K, Ogawa A, Okuguchi T, Kobayashi M, Suzuki M, Yoshimoto T. Post-

operative hyperperfusion syndrome in elderly patients with chronic subdural hematoma.Surg Neurol 2000;54:155–9.

90. Dunlop RJ, Campbell CW. Cytokines and advanced cancer. J Pain Symptom Manage2000;20:214–32.

91. Wein S. Sedation in the imminently dying patient. Oncology (Williston Park)2000;14:585–92; discussion 592, 597–8, 601.

92. Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill patient? SupportCare Cancer 1997;5:205–11.

93. Black KJ, Perlmutter JS. Septuagenarian Sydenham’s with secondary hypomania.Neuropsychiatry Neuropsychol Behav Neurol 1997;10:147–50.

94. Vaphiades MS, Celesia GG, Brigell MG. Positive spontaneous visual phenomenalimited to the hemianopic field in lesions of central visual pathways. Neurology1996;47:408–17.

95. Moyle J. The use of propofol in palliativemedicine. JPain SymptomManage 1995;10:643–6.96. Di Salvo TG, O’Gara PT. Torsade de pointes caused by high-dose intravenous haloper-

idol in cardiac patients. Clin Cardiol 1995;18:285–90.97. Nicolai A, Lazzarino LG. Acute confusional states secondary to infarctions in the

territory of the posterior cerebral artery in elderly patients. Ital J Neurol Sci 1994;15:91–6.98. Sanders KM, Stern TA. Management of delirium associated with use of the intra-aortic

balloon pump. Am J Crit Care 1993;2:371–7.99. Fernandez F, Holmes VF, Adams F, Kavanaugh JJ. Treatment of severe, refractory

agitation with a haloperidol drip. J Clin Psychiatry 1988;49:239–41.100. Swedlow DB, Schreiner MS. Management of Reye’s syndrome. Crit Care Clin

1985;1:285–311.101. Price J, Whitlock FA, Hall RT. The psychiatry of vertebro-basilar insufficiency with the

report of a case. Psychiatr Clin (Basel) 1983;16:26–44.

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102. SteinhartMJ. Treatment of delirium – a reappraisal. Int J PsychiatryMed 1978;9:191–7.103. Brenner WI, Lieberman AN. Acute clonidine withdrawal syndrome following open-

heart operation. Ann Thorac Surg 1977;24:80–2.104. Wendkos M. Acute Exhaustive Mania Sudden Death and Psychiatric Illness. New

York: Medical & Scientific Books division of Spectrum Publications, 1979:Chapter 10.105. Mann SC, Caroff SN, Bleier HR,WelzWK,KlingMA,HayashidaM. Lethal catatonia.

Am J Psychiatry 1986;143:1374–81.

Excited Delirium Checklist 439

Appendix B

Electrocution Diagnosis Checklist

In considering the possibility that a CEW (conducted electrical weapon) may

have induced VF (ventricular fibrillation), it is important to remember that:

� Nomedical, scientific, electrical, or engineering study has found that a CEWcan cause cardiac capture or induce VF in a human.

� In addition to other studies, the latest echocardiograpahic human studies havespecifically not found cardiac capture or VF during CEW discharge [1,2].

� In over 500 CEW medical studies of human exposures, many of whichoccurred across the chest, none induced cardiac capture or VF [1-15].1

� No closely monitored medical study of CEW field-use has found any case ofCEW induced VF [16,17].2

� In the entire history of medical, scientific, electrical, and engineering research,no study has found that the amount of electrical charge as delivered by abattery powered handheld CEW causes cardiac capture or induces VF inhumans [18].

All 10 criteria below would have to be present in order to have the possibility

that a suspect was electrocuted by the CEW.

Present? Not Present Criterion Rationale

From law enforcement reports

1. Probe mode deployment(instead of drive-stun).

Drive-stun mode is not able toinduce VF even in smallswine [19,20].

2. Use of TASER1 X26TM

CEW instead ofADVANCED TASERM26TM CEW (M26).

The M26 is unable to induceVF even in smaller swinewhile this has occurred inswine with the X26 [21].

3. Collapse within 15 s ofinitiation of a probe-modeapplication.3

The electrical induction of VFrequires 2–5 s [22–26].

Collapse in VF occurs within10 s of the VF initiation[27].

441

(continued)

From EMS report

4. A defibrillator shock appliedto the person within 8–10minofVF terminates theVF.Lawenforcement defibrillatormay have been used.

Electrically induced VF isterminated by adefibrillation shock 99.9%of the time [28].

5. Cardiac rhythm seen within20 min of the collapse is VF.This is demonstrated eitherby an external defibrillatorannouncing ‘‘shock advised’’or by a paramedic’s EKG(electrocardiograph)recording.

Most cardiac rhythms seenwith acute or chronic drugeffects or excited deliriumare not VF [29–32].

After 20 min of a possible VFthe rhythm may deteriorateto another type ofarrhythmia [33,34].

6. Initial presenting rhythm isnot asystole or PEA(pulseless electrical activity).

Asystole and PEA cannot beinduced with electricalstimulation. This criterion isnot valid after 20 min fromcollapse as VF willeventually deteriorate intoasystole or PEA [34].

From autopsy report

7. One probe was directly overa cardiac ventricle (mainchambers of the heart).

When VF has been induced inthe small swine, at least oneof the probes was over aventricle [19,35].

8. The probe directly over thecardiac ventricle penetratedthe skin and did not simplypenetrate or lodge in theperson’s clothing.

VF has only been induced evenin swine with a fully insertedprobe [21,35–37].

Note: typical probepenetration is around 4 mmor approximately half ofthe standard 9 mm barblength.

9. The penetrating probe overthe heart penetrated straightin and was not at an anglethat would negatively affectthe dart-to-heart distance.

Webster group predicted, fromporcine studies, that VFinduction would require avery thin person with a full9 mm barb penetration [35].

10. The dart tip-to-heartdistance is a maximum of8mm.4

The most extreme distancefound by the Webster groupfor VF induction – in swine –was 8mm with an average of6 mm, and a minimum of2 mm [35]. Swine are easy tofibrillate and thus present aconservative model [38–40].

Contributors: Mark Kroll, PhD, Richard Luceri, MD; Hugh Calkins, MD, DJ Lakkireddy,MD, Jeffrey Ho, MD.

442 Electrocution Diagnosis Checklist

1. There is a single anecdote of a prisoner with a pacemaker with a possiblebrief cardiac capture [41,42]. Some cardiac electrophysiologists feel that theinternal pacemaker recording reflects cardiac capture while others feel thatthe recordings only show the artifact of the CEW pulses. Regardless, oncareful analysis of this case, pacemaker experts have concluded that capture,if any, could only have been caused by the pacemaker lead carrying somecurrent to the inside of the heart. Thus, this case does not provide evidencethat a CEW – absent a pacemaker – could cause cardiac capture. There wasno harm to the prisoner or pacemaker.

2. An oft-cited anecdote, of possible electrically induced VF was misreportedwith material omissions [43]. A violent subject exhibiting most of the signs ofexcited delirium was briefly subdued with a short CEW discharge. Parame-dics were present and found a normal pulse and respiration after the CEWdischarge. After a 14-min delay, the subject collapsed and probably had anideoventricular rhythm. After an aggressive therapy of 3 defibrillation shocksalong with atropine and epinephrine, the subject finally had the VF stripshown in the published anecdote. A total of 23 min elapsed between theCEW application and the published VF strip.

3. Collapse at the end of a longer CEW application is generally due to the‘‘quiet period’’ after an agitated (or excited) delirium struggle which necessi-tated the long CEW application. Even before VF would theoretically beinduced, the rapid cardiac capture required to induce VF would have resultedin immediate loss of blood pressure and subsequent collapse [44]. This wouldhave ended the struggle.

4. Such a dart tip-to-heart distance is only possible in a very thin person with asmall BMI (body mass index). Skin-to-heart distances of 17 mm or less arerarely found in adults, especially males. Also, most law enforcement involvedcustody or arrest-related deaths involve males with an above-average BMI[29] and dart-to-heart distance significantly greater than 17 mm.

References

1. Ho JD, Dawes DM, Reardon RF, Lapine AL, Dolan BJ, Lundin EJ, Miner JR. Echo-cardiographic evaluation of a TASER-X26 application in the ideal human cardiac axis.Acad Emerg Med 2008.

2. DawesD, Ho J, Miner J. Echocardiographic evaluation of TASER X261 probe deploy-ment into the chest of human volunteers. Australas Coll Emerg Med Sci Assem 2008.

3. Dawes D, Ho J, Miner J. The neuroendocrine effects of the TASER X26: A brief report.Forensic Sci Int 2009:in press.

4. Vilke GM, Sloane C, Levine S, Neuman T, Castillo E, Chan TC. Twelve-lead electro-cardiogram monitoring of subjects before and after voluntary exposure to the Taser X26.Am J Emerg Med 2008;26:1–4.

5. Sloane CM, Chan TC, Levine SD, Dunford JV, Neuman T, Vilke GM. Serum troponinI measurement of subjects exposed to the Taser X-26. J Emerg Med 2008;35:29–32.

Electrocution Diagnosis Checklist 443

6. Ho JD, Dawes DM, Bultman LL, Moscati RM, Janchar J, Miner JR. ProlongedTASER1 use on exhausted humans does not worsen markers of acidosis. Am J EmergMed 2008:in press.

7. Ho J, Lapine A, Joing S, Reardon R, Dawes D. Confirmation of respiration duringtrapezial conducted electrical weapon application. Acad Emerg Med 2008;15:398.

8. Ho J,DawesD. The effect of the extended range electronic projectile (XREP) on breathing.Australian College of Emergency Medicine Winter Symposium. Newcastle, NSW, 2008.

9. Dawes DM, Ho JD, Johnson MA, Lundin E, Janchar TA, Miner JR. 15-Second con-ducted electrical weapon exposure does not cause core temperature elevation in non-environmentally stressed resting adults. Forensic Sci Int 2008;176:253–7.

10. Vilke GM, Sloane CM, Bouton KD, Kolkhorst FW, Levine SD, Neuman TS, CastilloEM, Chan TC. Physiological effects of a conducted electrical weapon on human subjects.Ann Emerg Med 2007;50:569–75.

11. Vilke G, Sloane C, Levine S, Neuman T, Castillo E, Chan T. Does the Taser causeelectrical changes in twelve lead ECG monitoring of human subjects. J Acad EmergMed 2007;Abstracts:257.

12. Vilke G, Sloane C, Bouton K, Levine S, Neuman T, Castillo E, Kolkhorst F, Chan T.Cardiovascular and metabolic effects of the TASER on human subjects. J Acad EmergMed 2007;14:104.

13. Moscati R, Ho J, Dawes D, Miner J, Reardon R, Heegaard W, Janchar T, Johnson M,Bultman L. Physiologic effects of prolonged conducted electrical weapon discharge onintoxicated adults. Soc Acad Emerg Med abstract issue 2007.

14. Levine SD, Sloane CM, Chan TC, Dunford JV, Vilke GM. Cardiac monitoring of humansubjects exposed to the taser. J Emerg Med 2007;33:113–7.

15. Chan T, Sloane C, Neuman T, Levine S, Castillo E, Vilke G, BoutonK, Kohokorst F. Theimpact of the Taser weapon on respiratory and ventilatory function in human subjects.Acad Emerg Med 2007;14:191–192.

16. Bozeman W, Winslow J, Hauda W, Graham D, Martin B, Heck J. Injury Profile ofTASER1 electrical conducted energy weapons (CEWs) Ann Emerg Med 2007;50:S65.

17. Eastman AL, Metzger JC, Pepe PE, Benitez FL, Decker J, Rinnert KJ, Field CA, FrieseRS. Conductive electrical devices: a prospective, population-based study of the medicalsafety of law enforcement use. J Trauma 2008;64:1567–72.

18. Ideker RE, Dosdall DJ. Can the direct cardiac effects of the electric pulses generated bythe TASER X26 cause immediate or delayed sudden cardiac arrest in normal adults? AmJ Forensic Med Pathol 2007;28:195–201.

19. Lakkireddy D, Wallick D, Verma A, Ryschon K, Kowalewski W, Wazni O, Butany J,MartinD, Tchou PJ. Cardiac effects of electrical stun guns: does position of barbs contactmake a difference? Pacing Clin Electrophysiol 2008;31:398–408.

20. Valentino DJ, Walter RJ, Dennis AJ, NagyK, LoorMM,Winners J, Bokhari F,Wiley D,Merchant A, Joseph K, Roberts R. Acute effects of MK63 stun device discharges inminiature swine. Mil Med 2008;173:167–73.

21. NanthakumarK,Billingsley IM,Masse S,DorianP,CameronD,ChauhanVS,DownarE,Sevaptsidis E. Cardiac electrophysiological consequences of neuromuscular incapacitat-ing device discharges. J Am Coll Cardiol 2006;48:798–804.

22. Biegelmeier G. Effect of current passing through the human body and the electricalimpedance of the human body: A guide to IEC-Report 469. VDE,-Verlag, Berlin: ETZ,1987.

23. Biegelmeier G, Lee WR. New considerations on the threshold of ventricular fibrillationfor a.c.shocks at 50�60 Hz. IEE Proc. 1980;127:Pt. A: 103–110.

24. Sharma AD, Fain E, O’Neill PG, Skadsen A, Damle R, Baker J, Chauhan V, Mazuz M,Ross T, Zhang Z. Shock on T versus direct current voltage for induction of ventricularfibrillation: a randomized prospective comparison.PacingClinElectrophysiol 2004;27:89–94.

444 Electrocution Diagnosis Checklist

25. Weismuller P, Richter P, Binner L, Grossmann G, Hemmer W, Hoher M, Kochs M,Hombach V. Direct current application: easy induction of ventricular fibrillation for thedetermination of the defibrillation threshold in patients with implantable cardioverterdefibrillators. Pacing Clin Electrophysiol 1992;15:1137–43.

26. Frame R, Brodman R, Furman S, Kim SG, Rot J, Ferrick K, Hollinger I, Gross J, FisherJD. Clinical evaluation of the safety of repetitive intraoperative defibrillation thresholdtesting. Pacing Clin Electrophysiol 1992;15:870–7.

27. Schipke JD, Heusch G, Sanii AP, Gams E, Winter J. Static filling pressure in patientsduring induced ventricular fibrillation.AmJPhysiol Heart Circ Physiol 2003;285:H2510–5.

28. Frame R, Brodman R, Furman S, Kim SG, Roth J, Ferrick K, Hollinger I, Gross J,Fisher JD. Clinical evaluation of the safety of repetitive intraoperative defibrillationthreshold testing. Pacing Clin Electrophysiol 1992;15:870–7.

29. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with sudden death ofindividuals requiring restraint for excited delirium. Am J Emerg Med 2001;19:187–91.

30. ParkKS,Korn CS,Henderson SO.Agitated delirium and sudden death: two case reports.Prehosp Emerg Care 2001;5:214–6.

31. DiMaio T, VJM D. Excited Delirium Syndrome Cause of Death and Prevention. BocaRaton: Taylor & Francis, 2006.

32. Swerdlow C, Kroll M, Williams H, Biria M, Lakkireddy D, Tchou P. Presenting rhythmin sudden custodial deaths after use of TASER1 electronic control device.Heart Rhythm2008;5:S44.

33. Allison JS,QinH,DosdallDJ,Huang J,Newton JC,Allred JD, SmithWM, IdekerRE.Thetransmural activation sequence in porcine and canine left ventricle is markedly differentduring long-duration ventricular fibrillation. J Cardiovasc Electrophysiol 2007;18:1306–12.

34. Veltmann C, Borggrefe M, Schimpf R, Wolpert C. Fatal inappropriate ICD shock.J Cardiovasc Electrophysiol 2007;18:326–8.

35. Wu J, Sun H, O’Rourke A, Huebner S, Rahko P, Will J, Webster J. Taser blunt dart-to-heart distance causing ventricular fibrillation in pigs. IEEE Trans Biomed Eng 2009:inpress.

36. Walter RJ, Dennis AJ, Valentino DJ, Margeta B, Nagy KK, Bokhari F, Wiley DE,Joseph KT, Roberts RR. TASER X26 discharges in swine produce potentially fatalventricular arrhythmias. Acad Emerg Med 2008;15:66–73.

37. Wu J, Sun H, O’Rourke A, Huebner S, Rahko P, Will J, Webster J. Taser dart-to-heartdistance that causes ventricular fibrillation in pigs. IEEETrans BiomedEng, 2007;54:503–8.

38. Dalziel CF, Lee WR. Reevaluation of lethal electric currents. IEEE Trans Ind Gen Appl1968;IGA-4:467–6.

39. Kroll MW, Calkins H, Luceri RM, Graham M, Heegaard W. Sensitive swine andTASER electronic control devices. Acad Emerg Med 2008;15:695–6.

40. Pak HN, Kim YH, Lim HE, Chou CC, Miyauchi Y, Fang YH, Sun K, Hwang C,Chen PS. Role of the posterior papillary muscle and purkinje potentials in the mechanismof ventricular fibrillation in open chest dogs and swine: effects of catheter ablation.J Cardiovasc Electrophysiol 2006;17:777–83.

41. Cao M, Shinbane JS, Gillberg JM, Saxon LA. Taser-induced rapid ventricular myocar-dial capture demonstrated by pacemaker intracardiac electrograms. J Cardiovasc Elec-trophysiol 2007;18:876–9.

42. Kroll M, Luceri RM, Calkins H. A very interesting case study involving a TASERconducted electrical weapon (CEW) used on a patient with a pacemaker. J CardiovascElectrophysiol 2007;18:E29–30; author reply E31.

43. Kim PJ, Franklin WH. Ventricular fibrillation after stun-gun discharge. N Engl J Med2005;353:958–9.

44. Swerdlow CD, Olson WH, O’Connor ME, Gallik DM,Malkin RA, Laks M. Cardiovas-cular collapse caused by electrocardiographically silent 60-Hz intracardiac leakage cur-rent. Implications for electrical safety. Circulation 1999;99:2559–64.

Electrocution Diagnosis Checklist 445

Index

A

Abdominal musculature, 168Abrasions, 34, 259, 264, 268, 276, 348,

382, 385Accountability sanctions, 391–2

administrative accountability, 392civil accountability, 391criminal sanctions, 391

AC-DC war, 17Acid-base

balancing of the respiratory system,175, 177

homeostasis, 169Acidosis, 85, 104, 106, 115, 143, 146–8, 171,

175, 182, 184, 221, 223, 311, 322,333, 359–60, 417

ACLU, see American Civil Liberties UnionAcoustic hailing devices, 45Adenosine triphosphate (ATP), 170Adrenaline, see epinephrine, 212, 216Adrenals, 180, 334–6, 353–6Adrenoceptors, 335, 353Aerobic metabolism, 169, 171Airburst non-lethal munition (ANLM), 45Alcohol

intoxication, 115, 220–1physiology, 219–20specific studies, 221withdrawal syndrome, 220

Alcoholism, 348–9, 357Alpert, Geoffrey P., 27, 257, 259–60Alpha-amylase levels, 182Alveolar dead space, 168–9AMA billing code, 361American Civil Liberties Union, 261–2,

276, 290American Medical Association (AMA),

360–1American Psychological Association, 418

Amnesty International, 262, 290, 304Amphetamines, 306–7, 330, 366, 371

abuse of, 303Anatomical composition of human

body, 197Anesthesia, 89, 92, 102, 112, 206,

208, 232Angel dust, see phencyclidine, 1, 306, 331Angrist, B. M., 366Anisotropic skeletal muscle, 73–4, 81Anodic current, 58Anorexic model, 67, 71ANOVA, 296Antemortem (hospital) specimens, 384Anterolateral thoracotomy, 96Anterolateral thorax, 87Anticonvulsant prophylaxis, 208Antipsychotic drugs, 303, 332–3Arcing, 51–2, 61, 284–5ARDs, see Arrest-related deathsAreas of confusion, 291–4

autopsy analysis, 293drug dysynergies, 293effects of electrical current on

breathing, 293electrocution, 291long duration shocks, 291–2

Arrest-related deaths, 183, 262, 290–1, 294,296, 301, 328

Arrhythmia, see Cardiac arrhythmiaArrhythmogenic properties, 216Arrhythmogenicity, 90, 329Arterial chemoreceptors, 170Arteriolar dilatation, 171Artificial heart program, 11Arylcyclohexylamine compounds, 331Asystole, 121, 145, 291, 293, 310, 321–2, 347,

357, 382Atherosclerotic plaque, 120

447

Atrial naturetic factor, 316Atrioventricular dyssynchrony, 95, 154Auscultation, 89Automatic external defibrillator (AED), 87,

382, 386, 408Autopsy, 290–1, 293–4, 301, 304, 307–8, 310,

319, 347–9, 369, 375, 380–1, 383–6,408, 421, 427–8

checklist, 382–3error, 295

Axon, 18, 58, 66, 187, 190, 357

B

BandAid, 29Baron-Esquivias, 183Barotrauma, 196Baseline blood testing, 221Baton, 3, 211, 242, 259, 264–5, 268, 290,

367, 381Baxter syringe pump, 102Behavioral abnormalities, 287Bell, L. V., 331, 333–4, 347, 367Bell’s Mania, 3, 331, 347–8, 360Benzoylecgonine, 114, 329, 336Berenbom, Loren, 223Berk, R. A., 260Bias and Causation theory, 427–8Biegelmeier, G., 292Bigeleisen, P., 171Binary logistic regression, 266, 268–9Binder, A., 24Bingham, Greg, 235Biochemical brain markers, 365–77Biomarker research, 145–9

creatine phosphokinase, 148lactate, 147myoglobin, 148potassium, 146troponin I, 146

Biomarkers, 144–6, 149–50, 365, 374blood serum, 144

Biopolymers, 196Bipolar recording catheters, 92Birmingham eye trauma terminology system

(BETTS), 203–4Bittner, E., 24Bizarre behavior, 3, 6, 164, 302, 366–7Blair, H. A., 123, 125Body mass index, 75, 294, 319, 419Bonferroni adjustment, 90Boo factor, 425Bootstrap technique, 285

Brainabnormalities, 322atrophy, 220

Brandishing, 284–5, 392–4Brave, Michael A., 389Brewer, James E., 283Broken bones or fractures, 268Bruises, 34, 259, 264, 268, 276, 382Bucking, 349–50Buprenorphine, 102Bureau of Alcohol, Tobacco, and Firearms

(BATF), 19–20

C

Cable theory, 190Calton, R., 225, 232Cambell, A., 260CaMKII (calmodulin kinase II), 316, 318Campbell, D. T., 422Canines and suspect injury, 276Canines, 260, 273–4, 276–7Cao, M., 224, 227Capacitance-stepped discharges, 87Capture zone of the darts, 53Carbon dioxide, hydration of, 169Cardiac abnormalities, 115, 134, 308

rhythm abnormalities, 136, 145Cardiac arrest and resuscitation, 109Cardiac arrhythmia, 69, 119–21, 123, 125,

127–8, 133–4, 147, 165, 171, 179,197, 216, 223, 233, 328–9, 335–7,354–5, 357, 408, 424

Cardiac capture, 77, 95, 119, 121, 153,160–1, 216

safety margins for, 78Cardiac contractility, 171Cardiac dysfunction, 143, 303Cardiac dysrhythmia, 95, 110, 114, 116, 137,

243, 302, 307, 310Cardiac electrophysiologists, 291, 304,

315, 408Cardiac excitability thresholds, 79Cardiac hypertrophy, 320, 337Cardiac implantable devices,

see Pacemakers (PM)Cardiac irritability, 138Cardiac myocyte excitation threshold, 77, 79Cardiac tissue alteration, 232Cardiac troponin levels, 116Cardiac vulnerability, 212, 329Cardiomegaly, 386Cardiomyocyte endoplasmic reticulum, 316

448 Index

Cardiomyopathy, 120, 220, 223–4, 316, 319,356, 380

Cardiopulmonary arrest, 309, 332–3, 347,349, 386

Cardiopulmonary resuscitation (CPR), 301,308, 311, 332, 350, 358, 381, 386

Cardiovascularcollapse, 179, 220disturbances, 96physiology, 115system, 137, 327, 333, 337, 348, 353

Castle doctrine, 389, 393Catecholamine

theory, 321toxicity, 337

Catecholamines, 321, 327, 329–30, 335–7,352–3, 355–7, 428

Cathodic current flow, 58Causation theories, 421Cause-and-effect relationship, 423Cellular damage, 144, 148–50Cellular destruction, 143, 146Central Intelligence Agency (CIA), 41Central nervous system (CNS), 2, 203,

306–29, 356, 367, 384Chan, H., 60Chan, T. C., 109, 276, 351–2Cheek, E. R., 193–4Chehade, M., 204–5Chemical fingerprint, 343Chemical irritant spray, 3, 5Chen, S. L., 205Cheng, Y., 192–3Chilbert, M., 291Choking, 404Chorioretinal adhesion, 205Chronic catecholamine, 333Chronic enlargement of the heart, 307Civilian model, 29Civilian riots, 42Clinical autopsy accuracy, 291Cloud, Samuel, 165Cocaine

abuse of, 303delirium, 367–8effects of, 90, 110, 114, 216, 321, 366,

369, 373-induced paranoia, 366–7intoxication, 254, 293, 332, 373

death due to, 254, 332, 369, 373psychiatric symptoms of, 366

mechanism of action, 328metabolites, 306

psychosis, 24, 366vasoconstrictor actions of, 329

Cohen, J., 420Cohen’s rule, 420Cold pressor tests, 183Cole, J. S., 18Common medical conditions associated with

sudden death, 302Concentric hypertrophy, 318Confidence level, 417–8Conflict resolution, 31, 35Congenital heart disease, 120Conner, G. J., 27Connexins, 187Consumer Public Safety Commission

(CPSC), 19–20Cook, T. D., 422Corneal abrasion, 305Corneal injury, 202Coronary artery disease, 120, 223, 307, 315,

320, 360Coronary flow reserve (CFR), 319Correlation coefficient, 423Creatine phosphokinase (CPK),

103, 148, 165,Cruel and unusual punishment standard,

397, 399–400Crush injuries, 149, 165CSI effect, 413–4CT scan, 64, 208Cuenca, Peter J., 41Current procedural terminology

(CPT), 360Curtis, H. J., 18Curtis, M., 425Custodial death data, 135Cyanoacrylate adhesive, 102

D

Dalziel, C. F., 12, 18–19Dart-to-heart distance, 96–101, 106, 114

effect of, 96measuring, 161–2

Daubert Trilogy, 410–4Davis, K. C., 24Dawes, D. M., 116, 167, 172, 179, 293Deadly force, 3, 5, 8, 24–6, 42, 44–5, 238, 258,

264–5, 269–71, 276Deale, O. C., 81Death investigation, 338–40,

342, 380Deductive reasoning, 415

Index 449

Defibrillation, 78, 81, 87, 98–9, 119, 121, 123,128, 188, 190, 223, 228, 232, 291,293–4, 307, 310, 321

absence of, 85Defibrillator, 78, 87, 98, 228, 232, 382, 386Dehydration, 309–10, 333Dementia, 63, 220Dennis, A. J., 94–5, 137, 153Depolarization, 58, 187, 189–90, 192–3, 212,

316–8, 320Depolarization-repolarization process, 316Detention operations, 41Di Maio, T. G., 304, 347Di Maio, V. J. M., 304, 347Diaphragm paralysis, 176–7Diastolic dysfunction, 308Diastolic potential (DP), 192Digitorum communis muscle, 60Dimsdale, J. E., 355Ding, J., 60Discoloration of the dura, 207Disney World, 31Doerner, W. G., 261Dopamine

receptors, 336–7, 369, 372reuptake transporters (DATs), 328–9,

356transporter, 336, 357, 368–71, 374

Dopaminergic agonists, 367Dopaminergic transmission, 371Dosdall, D. J., 119, 122–3, 125, 127Double-barrel microelectrode, 190Dragging, 404Drive-stun mode, 2, 7, 33–6, 67, 69, 72, 75,

176, 284, 293–4, 399–400, 402, 404Drug

induced psychosis, 408, 424disorders, differential diagnosis,

365–7influence of, 244, 248, 255, 393intoxication, 149, 183, 184, 294, 365, 380,

408, 424screening, 342toxicity, 303, 310

Du Boise, Reymond Emil, 15–16Dunham, R. G., 27, 259–60Dural perforation, 206–7Dysrhythmia, see Cardiac dysrhythmia

E

Eccentric hypertrophy, 316Echo images, 106, 154–5

Echocardiographicdata, 106, 156effects, 153–62monitoring, 153–4, 156, 159–61

Echocardiography (echo), 89, 95, 99, 106,114, 153–4, 156, 160–1

Ecstasy, 407, 424Ectopic heartbeat, 121–3Edison, Thomas, 17Efimov, I. R., 187Einziger, P. D., 196Elective replacement indicator,

223, 228, 232Electric rifle, 11Electric whaling apparatus, 19Electrical pulse incapacitation, 408, 424, 427Electrocardiogram (EKG), 16, 92, 106, 116,

135, 179, 183, 223, 319Electrocardiographic

effect, 133–41monitoring, 115

Electrocution, 6, 17, 143, 145, 165, 291,293, 302

Electrode conducting gel, 136Electromagnetic interference, 223–4Electromagnetism, 15Electrometer, 14Electro-muscular incapacitation, 63Electron microscopy, 188Electrophysiologic catheter, 212Electrophysiological abnormalities, 120Electrophysiological inhomogeneities, 94Electrophysiology, 15–16, 18Electroporation

assessment, 190–3, 196of cardiac and nerve cells, 187–97detection of, 189–induced ectopic activity, 190of lipid bilayer, 188

Emergency Medical Services (EMS), 240,360, 381, 408

Emergency Service Unit, 244, 246–50, 254–5Emergency thoracotomy, 137Emotionally disturbed person (EDPs), 241,

244, 249, 254Endocardium, 110Endophthalmitis, 206Endoplasmic reticulum, 165, 316Endothelial dysfunction, 353, 355Ends and bends stimulation, 54End-tidal gases, 169Enlargement and scarring (fibrosis) of the

heart, 307

450 Index

Epicardialpolarizations, 192surface, 75, 85, 89, 224

Epicardium, 75, 110, 189, 192Epidemiologic-engineering report, 12Epinephrine, see adrenaline, 92–4, 111,

137–8, 181–3, 212, 223, 309, 320,329, 334–7, 352–5

acute effects, 92–4effects of, 306infusion, 93

ERI, see Elective replacement indicatorErythroxylon coca, 328Ethanol

addiction, 220intoxication, 219

Ethidium bromide (EB), 189, 194Ethnographic studies, 415Evans, Michael A., 327Excitation thresholds, 66Excited delirium syndrome (EDS), 121, 133,

184, 302, 311, 327–8, 331–7,347–61, 365, 368, 371

cause of death in, 352–60polymorphism, 354postexercise peril, 354–7

hypokalemia and sudden cardiacdeath, 335

mechanism of death, 334Expiration, 168Extracardiac electrical activity, 232Eye

adnexal anatomy, 201–3anterior chamber, 202posterior chamber, 202

injuries by conductive electrical weapons,203–6

trauma, 203

F

Fallacies, 420–1Faraday, Michael, 15Fast, V. G., 192–4Fatal arrhythmia, 134, 328, 337, 356–7Federal Rules of Evidence, 412Fedorov, V. V., 187Felony murder rule, 422–3Ferris, L. P., 12, 18Finite element modeling (FEM), 65–7,

69–73, 75, 77–8, 79, 81Fishbain, D. A., 306, 332Flashlight, 5, 17, 259–60, 403

FN303 Less Lethal Launcher, 46Food and Drug Administration (FDA),

20, 82Force matrix, 27Force-related injuries, 258–63

impact of nonlethal weapons, 260–1OC spray, 261–2officer injury, 260suspect injury, 259–61

Functional residual capacity, 168Fundamental law of electrostimulation,

123–4, 126, 128Fyfe, J., 260

G

Galbraith, J. A., 190Gallant, P. E., 190Galvanic stimulation, 13Galvanometer, 16–17Gap junctions, 187, 195Garner, J. H., 24, 28Gas chromatography, 343Geddes, L. A., 124–5Gehl, J., 66General accountability themes, 390–1Generalized activating function theory, 190Generalized ordered logit models

(GOLM), 269Giants of Electricity and Bioelectricity,

12–16Ampere, Andre-Marie, 14Benjamin Franklin, 13Coulomb, Lt. Charles Augustin, 14Galvani, Luigi, 12–13Oersted, Hans Christian, 14von Guericke, 12

Global war on terrorism, 41Glutamatergic alteration, 331Goldman, D. E., 188Green fluorescent protein (GFP), 194Grill, W. M., 56Gulf war, 45Gumbel-Gompertz model, 289Gunn, Joshua, 327Gunpowder-propelled dart electrodes, 19Gunshot wounds, 268

H

Haegeli, L. M., 226, 232Hallucinations, 220, 327, 330–1, 333, 337,

347, 358, 366

Index 451

Han, D., 183Hands-on tactics, 258, 260–3, 272–3, 275

weapons for, 275Hard empty hand control, 264–6,

268, 270–1Hard-hand tactics, 272–5Harrison Narcotics Act, 328Harrison, R. L., 194Head injuries, 206–8Heart dart, 96–8, 113–4Heart failure, 120, 307–8, 354Heath shock proteins and hyperthermia,

373–4Hemidiaphragm, 170, 293Hemodynamic effects, 95Hemodynamic stability of the animals, 88Hemoglobin electrophoresis, 384Hemorrhage, 183, 205, 207, 302, 348, 350,

380, 386Henych, Mark, 23Hepatosplenomegaly, 386HERG, 315, 318, 320High-frequency sinusoidal components, 60High mobility multipurpose wheeled vehicle

(HMMWV), 46–8Hispanic subject autopsies, 295Ho, J. D., 133, 135, 139, 143, 219, 419Hogtying, method of, 351, 419Holden, S. J., 85Human stress response, 180Human volunteers, 81, 111–2, 114–6, 134–5,

156, 160, 212, 221, 223Humanitarian assistance, 41Hutson, H. R., 304Hypercarbia, 167, 171, 177Hyperexertion, 360Hyperkalemia, 85, 143, 146–7, 149, 164–5,

171, 336, 355–6Hyperpolarization response, 192–3Hypersympathetic state, 90Hypertension, 220, 307, 316, 318, 320, 335Hyperthermia, 182, 184, 196, 309–10,

327, 333, 336, 360, 365, 367–8,372–4, 382

Hypertrophycardiac, 320, 337concentric, 318eccentric, 316myocardial, 316, 318–20ventricular, 120, 319

Hypoglycemia, 183Hypothalamic receptors, 374Hypothalamus stimulation, 334

Hypothalamus-pituitary-adrenal (HPA),181–2

Hypoventilation, 169, 171, 175, 351Hypovolemia, 164Hypoxemia, 167, 171, 175, 177

I

Ideker, R. E., 119, 122–3, 125, 127Illegal drugs or excited delirium

behavior, 233Illegal stimulant intoxication, 211–6Immediate-response situations, 4Immobilization, 183Implantable cardiac devices, 223–34Implantable cardioverter defibrillators

(ICDs), 223–4, 228, 232–3, 291Implantable defibrillators, 78Improved flash bang grenade (IFBG),

45–6Incoherent shouting, 327, 333In-custody death, 1, 6, 24, 30, 75, 133, 165,

167, 179, 182, 184, 211, 257, 276,301–11, 383

factors associated with sudden, 304Individual serviceman non-lethal system

(ISNLS), 45–6Inductive reasoning, 415Inhomogeneities, 94Injury reduction effects, 275Injury severity index, 264Inspiration, 167–9Intercostal muscles, 168Intermediate weapons, 3, 264, 267, 275Internal injuries, 264, 268Internal Review Board (IRB), 418International Association of Chiefs of Police

(IACP), 242, 395International classification of diseases, 361International Electrotechnical Commission

(IEC), 291Intracellular electrolytes, 144Intramuscular ketamine, 88, 92Irreversible electroporation, 66, 71–3, 197Ischemic cardiomyopathy, 224Isotropic conductive gel, 74

J

Jauchem, J., 94, 102–5, 113, 172Joint locks, 44, 260, 264Joint non-lethal warning munitions

(JNLWMs), 45–6

452 Index

K

Kalamazoo Gazette, 242Kaminski, R. J., 257Karch, S. B., 293, 315Ketamine, 94, 306–7Kicking, 43, 260, 349, 402, 404Kleber, H. D., 367, 372Klinger, D. A., 31Knowledge acquisition, 413Koller’s discovery, 328Koslow, M., 56Kostecki, Geran, 187Kosten, T. R., 367, 372Kriger, M. Scott, 327Kroll, M. W., 179, 283

L

Lacerations, 264, 268Lactate dehydrogenase (LDH), 103, 170Lactic acidosis, 181Lakkireddy, D., 88–9, 91, 114, 223, 228–31Lapique, L., 123Laser painting, 285Laser pointing, 284Lateral vascular neck restraint, 379, 386Lauer, Andreas K., 201Law enforcement agencies, 3, 24, 26, 29–30,

63, 235, 245, 257–8, 261–3, 268,277, 283, 287, 290, 296

Law enforcement model, 29Law enforcement tools, 5Lee, W. R., 292Lens zonules, 202Lerman, B. B., 81Less-than-lethal force, 24, 29Levine, S. D., 135, 139Lewman, L. V., 351Life-threatening injuries, 45Ligature restraint, 379Liquid chromatography, 344Liver failure, 220Livshitz, L. M., 187, 196–7Logistic regression, 258, 264, 266, 268–9, 272

M

McDaniel, W. C., 86, 88, 113, 119, 128, 223Magic jar, 13McIntyre, C. C., 56McManus, John G., 41Magnitude of error, 418Manic-depressive exhaustion, 360

Marijuana, 331, 407Marinaro, Jonathan L., 201Mash, D. C., 365, 370Mass spectrometry (MS), 343–4Mass sympathetic discharge, 334–5Mathis, Jason, 257Maximal voluntary ventilation

(MVV), 352Maximum safe multiple (maxSM), 89–90Maxwell’s equations, 18Miami-Dade Police Department

(MDPD), 267models, 268–9

results, 272Meese, E., 11Membrane

depolarization, 94electroporation, 191, 194–5

Mental illness, signs of, 247Mental retardation, 348Mesloh, C., 23Metabolic, see acidosis

acidosis, 104, 164, 170–1, 309–10, 427lactate levels, 116physiology, 115

Methamphetamine, 2–4, 149, 184, 212, 216,315, 318, 322, 327, 329–30, 332–7,342, 344, 348, 353–4, 356–7, 361,365, 367, 369, 387, 407–8, 424

Meyer, G., 1, 243, 259Michalewicz, B. A., 352Microscopic remodeling, 316Midazolam, 311Mineralocorticoids, 181Minitheories, 416Mizrahi, J., 196MK19 launcher, 46M-mode tracing, 156–9Monoamine oxidase (MAO), 330Monophasic wave, 57Monster, A. W., 60Morabito, E. V., 261Mortality risk, 262Moscati, R., 165, 219Motor nerve, 18, 54, 56, 63, 65–6

activation, 65MRI scan, 64Multinomial logit models, 269Multiple hits theory, 320–2Multiple iterations, 36Muscle impedance matching gel, 97Muscle recovery period, 85Myocardial

Index 453

Myocardial (cont.)capture, 90, 223–4, 232damage, 182depolarization, 316dysfunction, 120–1hypertrophy, 316–20infarction, 120, 146, 216, 302, 315, 320ischemia, 90, 120–1, 181, 337,

353, 356–7necrosis, 128, 291remodeling, 316–8rhythm, 106

Myocardium, 93–4, 96, 120–1, 194, 195, 224,307–8, 318–9, 335, 337, 354–7

Myoglobin, 148–50, 164

N

Nanthakumar, K., 92–3, 119, 137–8, 216Nasal insufflation, 328, 330National Association of Medical Examiners

(NAME), 361Neunlist, M., 191–2Neurochemical testing, 386Neuroendocrine effects, 179–84Neuroleptic malignant syndrome (NMS),

360, 367Neuromuscular activation, 66, 81Neuromuscular stimulation, 70NEURON, 56–7Ng, W., 204–5Nifedipine, 193Noise reduction algorithms, 232Nondeadly force, 24Nonischemic cardiomyopathy, 120Nonlethal capability sets (NLCS), 45Nonlethal force, 24, 26–7, 31, , 44, 46, 270–1,

379, 398Nonlethal weapons, 3, 4–9, 23, 28, 35–6,

41–8, 63impact of, 261

Nonphysical force, 24Norepinephrine, 183, 320, 328–30, 334–7,

352–3, 355, 357effects of, 306

Null hypothesis, 414

O

O’Halloran, R. L., 351Objective reasonableness standard, 25,

395–6, 399–401Observe-orient-decide-act (OODA), 43–4

OC spray, 44–5, 182, 258, 261–4, 267,275–7, 290

See also Pepper sprayOchi, R., 194Oersted, 14Officer Injuries, 287On-duty injuries (ODIs), 236–8

additional costs, 237number of work days lost due to, 236–7overall annual odi cost, 238sources of injuries, 237–8

On-the-job training programs, 26Ontological assumption, 414Operations other than war (OOTW), 41Optical recordings, 190, 192–3Organ donation, 385Oxygen saturation, 86, 92, 96, 174, 351

P

Pacak, K., 183Pacchioni, A., 183Pacemakers (PM), 78, 121, 223–4, 228,

233, 415artificial cardiac, 211cardiac, 121, 211hypothetical, 78–9implantable, 77permanent (PMs), 224

Pain compliance techniques, 261Panescu, D., 63Paranoia, 327, 333, 336–7, 365–7, 371PCP, see PhencyclidinePEA, see Pulseless electrical activity (PEA)Peak, K., 5Pepper spray, see OC spray, 6, 36, 133, 182,

184, 220, 242–3, 257, 270, 305, 349,359, 367, 379, 399

Perchlorates, 45Pestaner, J., 332Peters, J. G., 407Petrocelli, M., 259PFT, see Pulmonary function testingPhaser-like device, 24Phencyclidine, 1–4, 149, 221, 306–7, 327,

330–4, 336–7, 342–4, 348–9, 356Photographic documentation, 381, 383–4Phrenic nerve, 170–1, 177, 293

dysfunction, 176Physical violence, 248–50, 400Physically resistant suspects, 276Pneumothorax, 121, 204Podorski, A. S., 86

454 Index

Point ofmaximal intensity (PMI), 89, 114, 162Police Executive Research Forum (PERF),

29, 242, 395Pollanen, M. S., 305Poor surrogates, 110Portable vehicle-arresting barrier (PVAB), 45Positional asphyxia, 261, 303, 308–9, 348,

350–1, 419Postexercise peril, 354–6Postmortem redistribution, 338, 341Preautopsy checklist, 382Probabilistic causation, 426Prolonged physical struggle, 290Prone maximal restraint position

(PMRP), 352Propidium iodide (PI), 189, 194Pseudomonophasic waveform,

51, 54, 56, 63Pseudo-scientific arguments, 17Psychostimulants, 366–7, 369, 373Psychotic symptoms, 365–6, 368, 371Pudiak, C., 183Pulmonary function testing, 351Pulse delivery probe, 87Pulseless electrical activity (PEA), 120–1,

291, 310, 321, 347, 357, 382, 408Pump failure, 82Punches, 44, 261Puncture wounds, 36, 276Purkinje fibers, 110

Q

QT prolongation, 318, 357

R

Radiofrequency ablation, 78Rattay, F., 53–4RCSD models, 266–7

logistic regression models of deputyinjury, 270

logistic regression models of suspectinjury, 271

results, 269Ready, Justin, 241Reardon, Robert, 153Reay, D. T., 351Refractory period, 188Reilly, J. P., 54, 66, 197Reiss, A. J. Jr., 24Remodeling, 315, 316, 318, 320Renal failure, 143, 149, 164, 383

Reporting tool, 30Respiratory

acidosis, 96, 104, 169, 171, 175arrest, 176, 327–8depression, 219impairment, 176, 180physiology, 167–71

anatomy, 170cellular respiration, 170

Restraint asphyxia, 348, 351Restraint-related death, 349Resuscitation, see Cardiopulmonary

resuscitation (CPR)Retinal detachment, 205–6, 208Reversible electroporation, 197Rhabdomyolysis, 85, 143, 149, 163–5, 220, 383

cocaine-associated, 368physiology of, 163–4symptoms of, 165

Rheoscopic frog, 12, 15Richardson, A. G., 56Risk management, 1, 235–40Rojek, Jeffrey, 257Ross, Wolf, 23Roy, O. Z., 86Runners heart, 318Ruttenber, A. J., 367

S

Safety index, 87–8St. Elmo’s fire, 13Salivary marker, 182Sampling error, 420Satel, S. L., 367Scalene muscles, 168Scarring, 307, 320Scharf, P., 24Screening tests, 343Sedatives, 112, 212, 307, 311Sensing thresholds, 228, 232Serum

bicarbonate, 175and skin effect, 143–50troponin, 103

Severe acidemia, see acidosis, 104Sharma, V., 192Sherman, L., 24Shock-induced hyperpolarization, 190Shocking to the conscience, 25, 397–8, 400Shootingavoidance tools, 5Short-duration exposures, 112, 135Sigmaopioid receptor, 337

Index 455

Sine wave, 15, 20, 52, 57–8, 86Sinus node, 211Sinus rhythm, 95–6, 106, 127, 154, 156,

159–61, 291Situation circle, 43Skeletal muscle

activation of, 52, 56, 63anisotropy of the, 70–1contraction, 51, 56, 106, 164, 167, 177,

179, 220force, 52, 56, 59–60rheobase and chronaxie values of, 53, 65

Skin-to-heart distance, 99–101, 106, 114, 161Skyjackers, 2Sloane, C., 179Small, K. M., 354Smith, M. R., 257, 259Snorting, 328Soft empty hand control, 264–6, 268–70, 276Soft-hand tactics, 272, 274Song, Y. M., 194Sonographer kneeling, 155Sonosite titan, 154Sorensen, D. W. M., 257Southall, P. E., 332Spatially extended nonlinear node model

(SENN), 54Specimen collection, 338–42

blood, 341specimen stability, 342tissue and hair, 341urine, 340vitreous humor, 341

Sprains, 259, 268, 276Standard deviation, 90, 124, 265, 418Standoffs, 4Sternocleidomastoid muscle, 168, 293, 386Stimulant abuse, 315–22, 325, 334, 358,

366, 374Strains and lacerations, 268Stratbucker, R. A., 11, 63, 113Stratton, S. J., 301Straw causation theory, 425Strength-duration relationship, 53–4, 122–4String galvanometer, 18

See also GalvanometerStrote, J., 304Structural heart disease, 94, 318, 320Stun devices, 63Stun gun, 2, 12, 20–1, 86, 220, 244, 367, 399Sudden Cardiac Death, 301, 315–22, 328,

335–7, 356, 358causes of, 120–1

Sudden in-custody death, see In-custodydeath

Sun, H., 68, 73, 81, 106Superficial skeletal muscles, 126Superhuman strength, 1–3, 327, 333, 367Suspect injuries, 287Suspect-related characteristics, 247Sweeney, J. D., 51Swine model, 416, 418Sympathetic-adrenal-medulla (SAM), 180,

182–4Sympathetic nervous system, 328–9, 334–5,

352–5, 357Symptomatic bradycardia, 233Systemic inflammatory response

syndrome, 309

T

Tachyarrhythmia, 156, 160–1, 232, 357See also Cardiac capture

Tachycardia, 95–6, 127, 154, 220, 228Taser CEW discharge, 96, 105–6, 113–5, 197,

293Tchou, P., 211, 293Telegraph equation, 18Telemetry monitoring, 228Temporal or association causation

theory, 425–6Temporality, 421–4Terrill, W., 25Tethered projectiles, 19Theory of generalizability, 418Thoracic pressure, 121Thoracoabdominal exposure, 176Threat of deadly force, 269–70Thrombus formation, 120Tip-to-heart spacings, 137Tomahawk cruise missile, 45Touch-stun, 33–4Toxicological analysis, 386Tracking equipment, 239Transcleral cryotherapy, 204Transdiaphragmatic exposure, 172Transmembrane action potential

morphology, 190–3Transmembrane electric field, 188Transmembrane potential, 121–8, 189–91, 193Traumatic apnea, 243Tremulousness, 220Tung, L., 191–3T-wave, 90, 182–3Twisting, 349

456 Index

U

Underwriters laboratories (UL), 12, 291United Nations peacekeepers, 42Unmanned ground vehicle (UGV), 48Urine toxicological tests, 306–7Usage rate versus deployment rate, model

of, 285Use-of-force incidents, 259–61, 263, 267, 405

V

Vacek, James L., 223Valvular disease, 120van der Waals attractions, 188Vanga, Subba Reddy, 223Vascular system, 306–7, 353Vasoconstriction, 316, 335, 353, 355–7Vehicle lightweight arresting device

(VLAD), 45Venous blood gas, 172Ventricular ablation, 110Ventricular arrhythmia, 93–4, 177, 216, 224,

357Ventricular capture, 89–90, 224, 292Ventricular dysfunction, 183, 320Ventricular fibrillation (VF), 20, 63, 68, 72,

82, 96, 104–6, 113–4, 119–20,136–8, 145, 154, 161, 211–2, 224–5,307, 321, 329, 408

cardiac death due to, 304danger of, 85induction of, 76, 87, 110, 212, 291safety margin for, 223threshold, 89

Ventricular hypertrophy, see hypertrophy,120, 319

Ventricular rhythm, 95, 154

Ventricular tachycardia, 95–6, 106, 120, 154,319, 328

Verbaldirection, 264, 267force, 264

Vilke, G. M., 109, 135, 139, 174, 179, 276Violence escalation scale, 253Volunteer testing vs. field conditions, 212Vulnerable period, 126

W

Walter, R. J., 105, 137Webster, John G., 85Wetli, C. V., 306, 332, 367, 379White, M. D., 241Witherspoon, S. Robert, 201Wittstein, I. S., 182Wolf, R., 23Wrestling, 43, 260Wu, J.-Y., 73, 75, 96–101, 106, 113,

136–7, 162

X

Xiphoid process, 89, 102, 106XREP1 device, 176Xylazine, 94Xyphoid process, 94

Y

Young, D. B., 355

Z

Zhou, X., 192Zolazepam, 102, 172

Index 457