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Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
Ex ds expo 2011.handout
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Ex ds expo 2011.handout

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Handout from a presentation at EMS Expo 2011. Most video and pictures removed.

Handout from a presentation at EMS Expo 2011. Most video and pictures removed.

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  • 1. Excited Delirium
    Michael Dailey, MD FACEPEMS Medical DirectorHudson Mohawk Region NY
  • 2. My disclaimers:
    No financial conflicts of interest
    I am not a law enforcement officer – this is a physician’s perspective with deference and respect for my colleagues
    There is no way to cover this concept in the time allowed, but let’s try
    Opinions expressed are my own
    I have taken open-source material from the internet and places such as YouTube— I have credited sources when available— If you know of a credit I should have made, please let me know
  • 3. Perspective
    Law enforcement
    Safety of public, person of concern and LEO
    Rapid control and restraint
    Dangerous?
    EMS
    Diagnosis and treatment when called to patient
    Risk from patient struggle
    Risk from sharps if ECW deployed
  • 4. Who are we?
    Emergency Medical Technicians
    Paramedics
    Physicians
    Nurses
    Firefighters
    NOT cops – perspective here will not be law enforcement
    Our part of care begins when patient is physically restrained
  • 5. Psychiatric calls and EMS
    Can we restrain?
    Can we protect ourselves?
    Who is responsible for the well-being of the person trying to injure us?
    We may have chemical restraint available, but how long does it take to work?
  • 6. Excited Delirium Syndrome = ExDS
    Get excited about it, but keep each case boring and stay off the cover of the paper
  • 7. Excited Delirium Syndrome = ExDS
  • 8. Does ExDS Exist?
    If I didn’t think so, we wouldn’t be here
    People die in law enforcement custody. Some EMS may be able to help mitigate; some not…
    Cardiomyopathy
    Drug overdose/stimulant abuse
    Metabolic acidosis
    Positional restraint/asphyxia
    Excited delirium
  • 9. Excited delerium
    1650 appears in British literature
    1849 Dr. Luther Bell (Bell’s Mania) described “acute exhaustive mania” inexplicable sudden death of psychotic
    1985 Dr. Charles Wetli (Miami) coined “excited delirium” to explain sudden death associated with cocaine
    1998 review of 21 cases of unexpected deaths in people in a state of “excited delirium” — 18 of which were people in police custody —all suddenly lapsed into tranquility shortly after restraint
  • 10. Where is ExDS not found?
    AMA
    ICD-9 Coding Manual
    DSM-IV
    Not a single diagnosis:
    10-12 different diagnosis codes can apply
  • 11. DSM IV Criteria for Delirium
    A. Disturbance of consciousness (i.e., reduced awareness about the environment) with less ability to focus, sustain, or shift attention.
    B. A change in cognition (e.g., memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better explained by a … dementia.
    C. Develops over a short period of time (usually hours to days) and tends to fluctuate during the course of a day.
    D. Evidence from the history, examination, or laboratory findings that the disturbance is caused by direct physiologic consequences of a general medical condition.
  • 12. What is ExDS?
    Delirium
    Agitation
    Combativeness
    Unexpected strength
    Elevated body temperature
  • 13. What do these people look like?
    Psychological behavior
    Communication behavior
    Physical behavior
    Physical exam characteristics
  • 14. Phases of the syndrome
    Delirium with agitation
    Sweating or appearance of high body temperature
    Acquiescence (Not mentioned in all sources)
    Respiratory compromise with potential respiratory arrest
    Cardiac arrest
  • 15. General Rule: Medical versus psychiatric
    Consider all potential medical causes before pronouncing behavior either “just alcohol” or “just psychiatric”
    Danger to providers does not decrease based on etiology
  • 16. Undifferentiated agitation
    Cocaine
    Methamphetamine
    Head trauma
    Intox (beer muscles)
    EtOHwithdrawal
    Psych
  • 17. Can you tell the difference?
    Psychiatric agitation
    Sympathomimetic intoxication
    Cocaine or methamphetamine
    Alcohol
    Withdrawal or intoxication
    Hypoglycemia
    Head injury
  • 18. Another disclaimer…
    I hate mnemonics!
    “I WATCH DEATH” – causes of delirium
    “TODS TIPS” – causes of altered mental status
  • 19. “I WATCH DEATH”
    I = Infection
    W = Withdrawal from drugs
    A = Acute metabolic disorders
    T = Trauma
    C = CNS pathology
    H = Hypoxia
    D = Deficiency in vitamins
    E = Endocrinopathy
    A = Acute vascular insult
    T = Toxins
    H = Heavy metals
  • 20. TODSTIPS
    T = Trauma, Acute head trauma
    O = Organ Failure, Cardiopulmonary, Renal, Neurologic, Hematologic, Endocrine
    D = Drugs
    S = Structural, Chronic subdural, Intracranial aneurysm, hydrocephalus, neoplasm or abscess
  • 21. TODS TIPS
    T = Toxins, Plants, CO, Heavy metals, Industrials
    I = Infections, Sepsis, Meningitis, encephalitis, 3° syphilis, PNA, RMSF, etc
    P = Psychiatric, Thought disorders, Mood disorder
    S = Substrate Deficiency, Anoxia/hypoxia, Hypoglycemia, Wernicke-Korsakoff's (thiamine), Pellagra (niacin), Folic acid, Vitamin B12
  • 22. Drugs (think “the anti’s”)
    Antineoplastics = Methotrexate
    Antiparkinsonian = Levodopa
    Antipsychotics
    Anti-cold = Antihistamine
    Antiobesity
    Other = Cimetidine, Thyroid hormones, Theophylline, Iron
    Drugs of abuse
    Antibiotics
    Anticholinergics
    Anticonvulsants
    Antidepressants
    Antiemetics
    Antihypertensives = Clonidine, Propranolol,
    Anti-inflammatory = Cyclosporin, NSAID, Steroid, Salicylate
  • 23. Physiology of ExDS
    Similar to Neuroleptic Malignant Syndrome
    Hyper-excited Dopaminergic neurotransmitters
    Increased firing of neurons leads to:
    Increased muscular activity
    Increased agitation
    Increased movement
    Reduced cognition
    Reduced thermoregulatory ability
  • 24. Physiology
    Stimulant abuse
    Hyperexciteddopaminergic neurons
    Metabolic acidosis
    Respiratory acidosis
    Hyperthermia
    Ultimately…
    Cascade or perfect storm
    All of the above combine for a disaster
  • 25. Response to Excited Delirium
    Increased muscular activity leads to:
    Increased temperature
    Increased BP
    Increased HR
    Increased metabolic activity leads to:
    Increased lactic acid
    Increased RR to blow off carbon dioxide
  • 26. Normal physiologic buffering
    CO2 + H2O = HCO3- + H+
    pH
    7.4
  • 27. Normal exertional buffering
    CO2 + H2O = HCO3- + H+
    pH nl
    RR
  • 28. Drug induced exertional buffering
    CO2 + H2O = HCO3- + H+
  • 29. Chest compression exertional buffering
    pH
    RR
  • 30. So what do the AHA guidelines say?
    Epi?
    Amiodarone?
    Lidocaine?
    Shock?
    Why 2 minutes of CPR?
  • 31. What do I do?
    I am a physician—I write protocols…
    Remember AHA ACLS is a guideline
    Created by committee
    Evidence based
    Consensus of experts when no evidence
    NO evidence in this case
  • 32.
  • 33. Lewis case from Palm Beach
    Horrible case: COPS was riding along
    I found this video on YouTube, but no clean copy
    http://blogs.browardpalmbeach.com/juice/2009/03/police_and_city_of_wpb_off_the.php
    http://www.wpbf.com/news/10547880/detail.html
    My sympathy to the officers and the Lewis family
  • 34. What should we do?
  • 35. LEO Perspective
    “Leave me alone so I can do my job”
    “Doc, don’t give me shit, you don’t know what it is like out there”
    “This guy was just beating me up, so I’m not giving him an inch”
    “Oh, shoot, you mean you aren’t going to get me in trouble…”
    “Oh, this is to protect me…”
  • 36. EMS Perspective
    Patient in custody is struggling
    How much is too much
    Sedation
    When to give mild sedation
    When to give high doses of sedation
    Should we check temperatures
    Acute deterioration
    Should we give bicarb?
  • 37. Principles of care in delirium
    Protect the staff
    Protect the person / patient
    Facilitate rapid diagnosis and management
  • 38. Consequences
    Rapid death
    Positional asphyxia
    Arrhythmias
    Hyperthermic death
    Untreated illness and morbidity
  • 39. RODEOS
    Restraint
    Oxygen
    Detrose
    Examination (PE, EKG, etc)
    Observation
    Serial assessment
  • 40. Restraint
    Physical restraint is temporizing
    Follow with medication / chemical restraint ASAP
  • 41. Restraints
    Anything that doesn’t get tighter
    Multiple people as a team
    Back away if resources not available
    Follow physical with chemical – not medically prudent to allow struggle
    Systematic review of assessment measures and pharmacologic treatment
    Clinical therapeutics
  • 42. Control goals
    Understand drugs and understand what is happening with the human being
    Principle very sick, may need IV
    IM vs IV vsblowdart
    What should endpoint be?
    Sedation?
    Or checking VS?
    Checking blood sugar?
  • 43.
  • 44.
  • 45.
  • 46.
  • 47. Choose the right drug
    Psychiatric or emotional cause
    Antipsychotic
    Withdrawal or sympathomimetic
    Benzodiazepine
    Unknown
    Benzodiazepine
  • 48. Dopamine and delirium
    Dopamine pathways are implicated
    Chronic cocaine up-regulates dopamine receptors
    Cocaine and other sympathomimetics release dopamine as a neurotransmitter
    Turning up the heat…
    Need to “turn down” the neurotransmitters
  • 49. Why benzodiazepines?
    Enhance GABA
    GABA (Y-aminobutyric acid) is an inhibitory neurotransmitter that reduces dopamine release
    Increase GABA, decrease dopamine; thus, excitement is decreased
    Turns on the AC…
  • 50. Benzodiazepines
    Limited resp depression
    But potential obstructive problem if flat on back
    …unless alcohol involved then potential problem
    BEWARE supplemental oxygen
    how low can they go…
    watch ventilatory status
    Midazolam has most rapid onset of action IM or IN
  • 51. What about the old…5 and 2?
    Haloperidol 5 mg mixed with
    Lorazepam 2 mg
    Single syringe IM
    Is it really that bad?
    “This cocktail proves you understand neither pharmacology, nor physiology” Bob Hoffman, MD FACEP, FACET, Director NYC Poison Control Center
  • 52. Haloperidol - Haldol
    Anticholinergic, so it actually decreases ability to thermoregulate
    Decreases seizure threshold
    Black box for QT prolongation
    Not faster than benzodiazepines
  • 53. Now what?
  • 54. What if they go into cardiac arrest?
    Uninterrupted compressions
    PEA
    Sodium bicarbonate – 2 amps
    Asystole
    Sodium bicarbonate – 2 amps
    Ventricular fibrillation
    Sodium bicarbonate – 2 amps
    Hold on initial shock for 2 minutes
    Hold on initial epinephrine
  • 55. Who dies in custody without trauma?
    97% between 34 – 44
    11% chemical spray
    8% impact weapons
    27% ECD weapons
    63% struggle with LEO
    53% ingested street drugs
    60% exhibited bizarre behavior
    Jeff Ho,Policemag, Aug 2005
  • 56. Recognition
    Any case that begins as bizarre presentation
    Another “EDP” call
    An “assist the police”
    Intox or drugged up
    Naked patients should always be a significant concern…
  • 57. Take home message
    If everything goes well, these calls are boring
    If all goes badly reach for bicarb first
    Prevention is key, work with law enforcement
    Early chemical restraint is the key to safety
    Safest agents are benzos, but use them safely—constant monitoring
  • 58.
  • 59.
  • 60. Thank you.Questions, thoughts or comments:
    mwd101@gmail.com

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