Excited delirium syndrome

CCASESTUDY

 6 police/security struggling to restrain! Swearing obscenities, unable to reason with! Incredibly diaphoretic, & hot to touch! Unable to do vitals! Given 15 mg IMI Midazalam no effect! 20 mins later still being restrained!Then Stops resisting, quiet, not moving!

 Placed on monitor. In asystole. Given 40 mins standard ACLS. No ROSC!

COD: ExcitedDeliriumSyndrome

 1St documented case 150 years ago “Fever with Mania” Around 250 deaths per year in USA Majority literature/cases – USA Not universally fatal Recognised as a unique syndrome

 The term excited delirium, a condition described as an individual totally out of control, unable to be reasoned with or talkdown, & possessing great feats of strength is somewhat vague & ill defined; but is well known to any police officer, paramedic, or emergency clinician.  Fason, C. & Schneider, G. (2009).

 The typical course of EDS patient involves:  Acute drug intoxication  Hx of mental illness.  Struggle with law enforcement.  Require physical or noxious chemical control measures.  Sudden & unexpected death.  Autopsy fails to reveal cause.  ACEP Excited delirium Taskforce (2009)

 Males. Psychostimulant drugs use. Suspected/known psychiatric illness. Failure to respond to police. Unusual physical strength/stamina. Nudity/inappropriate clothing. Erratic/violent behaviour.

 Complex & poorly understood.Thought to be from: Dysregulated dopamine transporters Elevated heat shock proteins Catecholamine surge Severe acidosis plays a role in cardiovascular collapse.

 Tachypnea Tachycardia Hyperthermia Hypertension Acidosis Rhabdomyolysis

 Dubious reports of taser’s causing death. Circumstantial evidence only. Political & social gains would have us thinking otherwise!Bottom line: Excited delirium causes deathsNot: Taser’s, OC spray or being in custody!

 Stop the downward spiral of:  Struggling to exhaustion  Hyperthermia  Acidosis  Cardiac depressionBy allowing: Gain control – provide sedation/supportive care!

 This is a time sensitive disease!It’s both a:  Behavioural emergency!And a  Medical emergency!

P: Psychological issues.R: Recent drug/alcohol use.I: Incoherent thought process.O: Off (taking clothes off) & sweating.R: Restraint to presence.I: Inanimate objects: violent to-ward shinny or glass objects.T: Tough, unstoppable, superhuman strength.Y: Yelling.

 No “chain of survival” “Chain of Disaster” – we are the last link! Team approach  Nurse, Senior Dr, Security  Monitored area  Rapid sedation is the priority  Use least restrictive restraint method

 Team sport Enough staff to control individual Avoid seclusion rooms Physical restraints till sedation achieved Avoid prone position  Restraint Asphyxia Syndrome

 Needs to be prompt and rapid!1ST Line: Benzodiazepines (Midazolam)2ND Line: Antipsychotics (Droperidal) or Ketamine3rd Line: Rapid Sequence intubationRoutes: IV (preferred), consider IN,IMI, IO

Once sedation achieved: Check: Temp, BSL, CK, Lactate and PH. 12 lead ECGHyperthermia (Temp >38.5 risk of MOF): Actively cool, fluidsRhabdomyolysis: Fluids, IDC.

 Behavioural & Medical Emergency! Identify patients at risk! Require rapid sedation & supportive care for good outcome! Educate your colleagues/EMS/police on EDS!

kaneguthrie@gmail.com

Excited delirium syndrome

by Kane Guthrie on Oct 18, 2012

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