Excited delirium.ppt
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Excited delirium.ppt



Power Point presentation on Excited Delirium. Short video embedded to illustrate key points. Please feel free to share and use.

Power Point presentation on Excited Delirium. Short video embedded to illustrate key points. Please feel free to share and use.



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  • TdP
  • Most medications or street drugs affect one or more of the neurotransmitters in regards to ExD. HPI/events is imperative.

Excited delirium.ppt Excited delirium.ppt Presentation Transcript

  • Excited Delirium Nikki Arana-Oquendo NREMT-P
  • Objectives • To expand the knowledge base of field providers regarding Excited Delirium • To help the field providers identify and treat Excited Delirium
  • History • 1800’s Bell’s mania/ exhaustive mania ―exhaustion due to mental excitement‖ (http://www.exciteddelirium.org/) • 1960’s Neuroleptic Malignant Syndrome (NMS) was believed to occur as a potentially fatal untoward effect of antipsychotic drugs • 1985 During crack cocaine epidemic Dr. C. Welti and David Fishbain published a paper regarding ExD.
  • Welti • Reported excited delirium in a cocaine body packer/ ―body stuffers‖ • Medical studies regarding stimulant and hallucinogenic increased • Toxicology screening increased • Most accepted studies regarding Excited Delirium performed post mortem on cocaine users.
  • Definition • No single definition • American College of Emergency Physicians joined with the Association of Medical Examiners to categorize Excited Delirium as a clinical syndrome. • True medical condition
  • Signs and Symptoms • • • • • • • Variation of all or a few Bizarre or aggressive behavior Shouting Paranoia and panic Shift in reality Violence toward others Unexpected physical strength
  • Signs • • • • • Hyperthermia Tachycardia Prolonged QT Arrhythmia Death
  • Misconceptions Regarding ExD • Primary cause is Police brutality • Only cause is cocaine /stimulant induced delirium • There are no field treatments for Excited Delirium • There are no life threats associated with Excited Delirium
  • Pathophysiology What We know • Not exclusive due to lack of field studies/ accurate H&P • Believed to have a genetic component • Altered Dopamine processing/ pathways
  • Review • ―Dopamine is an essential neurotransmitter in several neural pathways regarding movement, hypothalamic function, positive behavioral reinforcement and higher cognitive function.‖ (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/)
  • Neurotransmitters • • • • Acetylcholine Dopamine Norepinephrine Serotonin
  • Note Worthy • While drug use is believed to be the most common cause, psychiatric emergencies and medication complications should also be considered. • Use of synthetic drugs like Bath Salts and Spice whose chemical composition is rapidly evolving should also be considered.
  • Differential Diagnosis Borderline Personality Disorder Delirium Dementia Postpartum Depression Post-Traumatic Stress Disorder Schizoaffective Personality Disorder Alcohol Withdrawal Substance Abuse Psychotic Break TBI
  • Borderline Personality Disorder • Effects; Moods, Relationships and Behavior • May occur with periods of psychotic episodes • High comorbid rates of substance abuse, anxiety, depression, self-harm, eating disorders and suicide National Institute of Mental Health http://www.nimh.nih.gov/health/trials/alzheimers-disease-and-other-memory-disorders.shtml
  • Dementia • Not a specific disease rather a wide range of symptoms • Memory Loss • Personality Changes • Communication and language struggle • Attentive struggle • Visual Perception • Judgment and Reasoning changes
  • Dementia Causes • • • • • • Medication (side effects) Vitamin Deficiency Substance Abuse Thyroid Depression Alzheimer's Alzheimer’s Association http://www.alz.org/what-is-dementia.asp
  • Post Traumatic Stress Disorder • Genetic Component • Comorbidities similar to other behavioral disorders • Flashbacks, nightmares, insomnia, frightening thoughts, avoidance, feeling of numbness, sadness, worry, anger http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
  • Schizoaffective Disorder • Schizoaffective disorder is a mental condition that causes both a loss of contact with reality (psychosis) and mood problems. • Genetic • Not common in children PubMed http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001927/
  • SXS • Changes in appetite and energy • Disorganized speech that is not logical • False beliefs (delusions), such as thinking someone is trying to harm you (paranoia) or thinking that special messages are hidden in common places (delusions of reference) • Lack of concern with hygiene or grooming • Mood that is either too good, or depressed or irritable • Problems sleeping • Problems with concentration • Sadness or hopelessness • Seeing or hearing things that are not there (hallucinations) • Social isolation • Speaking so quickly that others cannot interrupt you Pubmed http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001927
  • Psychosis • Usually organic • Characteristic most common is loss of contact with reality • Impairment of mental function that prevents normal activity
  • Psychotic Break A psychotic break is a break with reality, caused by a dopamine imbalance in the brain, resulting in delusions and/or hallucinations, usually auditory.
  • Five A’s list of symptoms that commonly occur before a psychotic break:  Affective disorder – Blank stare. Flat affect or mood.  Associative disorder – Losing train of thought repeatedly.  Ambivalence – Short-tempered or explosive outbursts for no reason.  Anhedonia – Has difficulty laughing or crying, or laughs or cries inappropriately.  Blunted emotions.  Autism – In a world of his own. May not notice someone calling his name.
  • After the Break • Delusions of grandiosity or paranoid delusions of persecution • Hallucinations
  • Schizophrenia • • • • Fragmented emotional and thought perception Gross distortion of reality Social withdrawal Includes two or more of the following SxS delusions, hallucinations, disorganized speech, disorganized behavior, catatonia
  • Post-Partum Depression • What are your pertinent positives and negatives? • Most underdiagnosed and undertreated population
  • SxS Post Partum Depression • • • • • • • • • • • Mood swings Anxiety Sadness Irritability Crying Decreased concentration Trouble sleeping Loss of appetite Insomnia Intense irritability and anger Overwhelming fatigue • Loss of interest in sex • Lack of joy in life • Feelings of shame, guilt or inadequacy • Severe mood swings • Difficulty bonding with your baby • Withdrawal from family and friends • Thoughts of harming yourself or your baby • Untreated, postpartum depression may last for many months or longer.
  • Postpartum Psychosis With postpartum psychosis — a rare condition that typically develops within the first two weeks after delivery — the signs and symptoms are even more severe. Signs and symptoms of postpartum psychosis may include: • Confusion and disorientation • Hallucinations and delusions • Paranoia • Attempts to harm yourself or your baby
  • Substance Abuse • Genetic Component • Many comorbidities with other behavioral disorders • Escape
  • Alcohol Withdrawl / Alcohol Related Psychosis • • • • • • • • • • Life Threatening Potential Distortion Hallucination Tachycardia Diaphoresis Febrile Hypertensive Seizures Tremors Alcohol Related Psychosis usually resolves with abstinence
  • Bath Salts and Spice • Ever evolving chemical composition that makes identification and treatment difficult • Often polysubstance use present • Just as likely to be volatile, presenting field providers with safety issues
  • TBI • • • • • • Occurs with primary and secondary brain injuries Personality changes Mood swings Comorbidities of other behavioral disorders Depression No known evidence of correlation of severity of injury, age, comorbid factors and PTSD. Studies are ongoing and inconclusive.
  • Safety First or Not At All
  • Field Management • Include Law Enforcement • Physical restraints may be necessary to ensure safety during transport • Traditional 4 Point restraint issues • Consider use of pharmacological restraints • Review medications and doses before you need to use them • Involve EMS Consortium
  • Field Management • Sedation for this patient population is not currently considered for all ExD patients • Causes for lack of sedation use unknown, also not widely studied. • Transport time may be common cause • Limited Scope of Practice in regards to ExD
  • Bernalillo County EMS Protocol • • • • MISC-5 Patient Restraint Include but not limited to 5mg Midazolam IM Repeat of IM dosing requires MCEP
  • Field Management • IV fluids should be considered but not at the expense of provider safety • A patient with tachycardia may also experience unexpected arrhythmias (due to diaphoresis and agitation monitor use may not be possible) • Anticipate worsening condition that occurs suddenly
  • Hospital Management • • • • • • • • Safety Precautions-Many hands Sedation 12 lead and cardiac monitoring ETCO2 Monitoring/Airway Labs-Chemistry, CKMB, Lactate IV Fluids Monitoring Foley Catheter-Monitor Urine Output
  • Agent (Trade Name) Available Routes Dosing (mg)* Onset (min) Duration (min) Midazolam (Versed) IN IM IV IM IV IM IV IM IM IV IM 5 5 2-5 4 2-4 10 5-10 10-20 5-10 5 2.5 10-20 3-5 10-15 3-5 15-30 2-5 15-30 2-5 15 10 20 10 10 30-60 120-360 30-60 60-120 60-120 15-60 15-60 180-360 180-360 120-240 120-240 240 Olanzapine (Zyprexa) IM 10 15-30 24 hours Ketamine (Ketaset, Ketalar) IM IV 4-5mg/kg 2mg/kg 3-5 1 60-90 20-30 Lorazepam (Ativan) Diazepam (Valium) †Haloperidol (Haldol) †Droperidol (Inapsine) Ziprasidone (Geodon) ††IV IN: Intranasal; IM: Intramuscular; IV: Intravenous * Typical adult dosing for severe agitation. † The Food and Drug Administration has issued “Black Box” warnings regarding potential serious adverse effects (QT pro-longation and torsades de points) with these agents. Clinicians should use their clinical judgment regarding the risk / benefit ratio on a case by case basis. †† Though widely used in clinical practice, Haloperidol is not FDA approved for intravenous administration. (For adequate control of ExDS, the above doses are conservative and describe a reasonable starting point. Clinical effect in ExDS may require doses greatly in excess of those for traditional med-ical use in other conditions). Table 5 Excited Delirium Task Force, White Paper ACEP 21(08),September 10,2009
  • Cascade of Events • • • • • • Metabolic Acidosis Hyperthermia Rhabdomyolysis Tachyarrhythmia Cardiac collapse Death
  • Conclusion • Excited Delirium is a medical emergency requiring safety as the primary tenet of care • Safe transport and use of additional resources imperative • Use of sedation and restraints for patient and provider safety should be considered • When is doubt contact MCEP/ EMS Consortium