Excited Delirium

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  • Version 13 5/06
  • Version 13 5/06
  • Version 13 5/06
  • First Responders cast the broad net, Medical personnel are left to determine the root cause. Pharmacological and psychological are most frequent. Version 13 5/06
  • First Responders cast the broad net, Medical personnel are left to determine the root cau Version 13 5/06
  • Version 13 5/06 Explain Delirium, different types Hyperthermia > 102 degrees or in absence of a thermometer, hot to touch Cardiac Arrest most likely to occur following an sudden and immediate tranquility
  • Dr Curtis is presenting to AMA to have it recognized as a disease Version 13 5/06
  • Version 13 5/06
  • Version 13 5/06
  • Version 13 5/06
  • Version 13 5/06 Locate and copy Texas’ mental health emergency commitment. Most common mental illness associated with ED/SDS is bi-polar in US. Schizophrenia in Canada.
  • 2/3 of cases due to stimulant drug use 1/3 due to mental illness Version 13 5/06
  • Version 13 5/06
  • Wren Agitation Contributes to muscle exertion, tissue breakdown causing release of cellular content (lactic acid and potassium) May be an early warning sign of impending sudden death Could progress to violent /combative behavior Acidosis / Rhabdomyolysis Breakdown of muscle tissue during extreme prolonged exertion releasing toxic compounds into blood May cause massive fluid shifts away from circulating volume Reduces threshold for arrhythmias May already be present prior to ECD use Hyperthermia >102 Result of extreme, prolonged exertion “Run Away” metabolism Contribute to the agitation and acidosis Early predictor of mortality Seemingly invulnerable physically, the patient may be experiencing a cluster of life-threatening physiological stresses including hyperthermia, a change in blood acidity, electrolyte imbalances, a breakdown of muscle cells, and a leaching of cellular contents into the blood stream, all of which puts the heart significant risk of failure. Version 13 5/06
  • There is something to say about sedation minimizing the patients ACTIVE RESISTANCE to physical restraints The key is you have to administer enough to achieve sedation Valium – We don’t carry enough Haldol – Long onset 30 min IM Versed – We don’t give enough 2-5 mg IM or a max of 20 mg IV Ketamine – 5mg/kg IM or 1.5 mg/kg IV Use sedation to help package patient for transport Version 13 5/06
  • Transport NOT in a patrol car, EMS should transport immediately to hospital, preferably a trauma center Urgent and Rapid transport Take extra manpower, police if handcuffs are used as restraints Early Alert to hospital Version 13 5/06
  • What’s wrong with this picture?? Prone or Scoop Sandwich positions are NOT acceptable Supine or on in Left Lateral Recumbent positions are preferred Version 13 5/06
  • ED Patients suddenly die, usually immediately following cessation of combative resistance when not associated with sedation Normal Saline is fluid of choice Lactated Ringers may contribute to Acidosis (increase potassium which will cause heart to be hypersensitive to adrenal substances causing arrhythmias) Treat hypoglycemia with D50 and/or Glucagon If suspected alcohol intoxication, treat with Thiamine 100 mg IV Version 13 5/06
  • Sedate, Lower Temp, and Neutralize Acid Miami-Dade Fire / EMS Give Versed via MAD, IV cooled fluids to lower body temperature then Bicarb to raise ph Nashville Fire / EMS First responders in Nashville have been using sedatives at street level for highly agitated patients for 2 years. Used 110 times, no negative effects, 8 - ED patients, all survived Champaign, Il Standard policy/protocol county wide all agencies Starts in dispatch with call takers Involves EMS early and brings medics in to help with restraint by sedation Ketamine sedation Appleton, WI You saw the video EMS uses Haldol for sedation, no cooling or bicarb therapy Version 13 5/06
  • If it’s not documented, it didn’t happen! Don’t let your patient care report be used as a weapon to attack the police If allowed to remove probes, document location, is the probe intact, don’t cut/break wires, the name of the officer you released them to What types of treatments were performed and the response the patient had to those treatments Be as detailed as possible, most patients die and the more detailed you are the better position you will be in years later if sued Version 13 5/06
  • JERRY Carefully review policies & procedures Liability is important but should not be your number one priority. Conduct training on sudden death syndrome with all first responders, call takers, and correctional staff. Version 13 5/06
  • Version 13 5/06
  • Excited Delirium

    1. 1. <ul><li>Presented by: </li></ul><ul><li>Jerry Staton </li></ul><ul><ul><li>Affordable Realistic Tactical Training </li></ul></ul><ul><ul><li>Senior Master TASER Instructor </li></ul></ul><ul><ul><li>In-custody Death Specialist </li></ul></ul>What first responders need to know Excited Delirium
    2. 2. <ul><li>Distinguish between Excited Delirium & mental illness </li></ul><ul><li> </li></ul><ul><li>Provide best care for the patient </li></ul><ul><li>Minimize risk and liability to all first </li></ul><ul><li>responders (police, fire, EMS) </li></ul>Goals
    3. 3. <ul><li>ED is a Medical Emergency </li></ul><ul><li>Police – Contain, Capture, Control, & Restrain </li></ul><ul><li>Medics - Sedate, Treat, & Transport </li></ul>Excited Delirium (ED)
    4. 4. <ul><li>A label for any person displaying a specific set of behaviors or traits which puts them at an increased risk for dying while in your care. </li></ul>Label
    5. 5. <ul><li>Metabolic </li></ul><ul><li>Infectious </li></ul><ul><ul><li>Pharmacological </li></ul></ul><ul><ul><li>Psychological </li></ul></ul>Causes
    6. 6. <ul><li>Phase I: Hyperthermia (not always) </li></ul><ul><li>Phase II: Delirium (incoherent) </li></ul><ul><li>Phase III: Respiratory Arrest </li></ul><ul><li>Phase IV: Cardiac Arrest </li></ul><ul><li>Who Needs Training </li></ul>Phases of ED
    7. 7. <ul><li>All first responders need to know the capabilities of the other players. </li></ul>
    8. 9. Affordable Realistic Tactical Training
    9. 10. <ul><li>Plaintiff’s attorneys argue Excited Delirium is not a medically recognized disease. </li></ul><ul><li>They are right </li></ul><ul><li>The American College of Emergency Physicians and the AMA have recently recognized Excited Delirium as a Condition. </li></ul>Not a Disease
    10. 11. <ul><li>Manic Excitement </li></ul><ul><li>Abnormal Excitement </li></ul><ul><li>Psychomotor Excitement </li></ul><ul><li>Psychomotor Agitation </li></ul>Agitation Delirium Delirium, Mixed Origin Delirium, Drug-Induced
    11. 12. <ul><li>Bell’s mania </li></ul><ul><li>Delirium grave </li></ul><ul><li>Acute delirium </li></ul><ul><li>Excited catatonia </li></ul><ul><li>Lethal catatonia </li></ul>
    12. 13. Sudden Unintended Unexplainable Negative autopsy Excited Delirium Syndrome
    13. 14. <ul><li>Sudden Deaths in the U.S. </li></ul><ul><li>1849 Dr. Bell, 40 patients / 30 deaths </li></ul><ul><li>1881 Term ED in medical literature </li></ul><ul><li>1849-1947 Similar reports of SD </li></ul><ul><li>1948-1960 No SD reports (sedation) </li></ul><ul><li>1960-1980 SD reports reappear </li></ul><ul><li>1980s Drastic increase in SD (cocaine) </li></ul>History
    14. 16. <ul><li>Indicators for ED are similar to ones exhibited by a mentally ill person or an overdose </li></ul><ul><li>Medical Emergency </li></ul>Mental Illness or ED?
    15. 17. <ul><li>91 to 99% male </li></ul><ul><li>Between the ages of 35-44 </li></ul><ul><li>Usually involved in a struggle </li></ul><ul><li>Often follows bizarre behavior </li></ul><ul><li>The long-term use of illegal drugs </li></ul><ul><li>Mental issues (bipolar & schizophrenia) </li></ul>Who is at Risk?
    16. 18. <ul><li>Naked </li></ul><ul><li>Running wildly </li></ul><ul><li>Running in traffic </li></ul><ul><li>Often demonstrate: </li></ul><ul><ul><li>Violent behavior </li></ul></ul><ul><ul><li>Bizarre behavior </li></ul></ul><ul><ul><li>Aggression toward glass </li></ul></ul>
    17. 19. <ul><li>Unlimited endurance </li></ul><ul><li>Superhuman strength </li></ul><ul><li>Reduced sense of pain </li></ul><ul><li>Muscle rigidity </li></ul><ul><li>Violently resist: </li></ul><ul><ul><li>capture / control / restraint </li></ul></ul><ul><ul><li>before / during / after arrest </li></ul></ul>
    18. 20. <ul><li>Hallucinations </li></ul><ul><li>Intense paranoia </li></ul><ul><li>Extreme agitation </li></ul><ul><li>Emotional changes </li></ul><ul><li>Disoriented about: </li></ul><ul><ul><li>Time/Place/Purpose </li></ul></ul><ul><li>Delusional </li></ul><ul><li>Scattered ideas </li></ul><ul><li>Easily distracted </li></ul><ul><li>Psychotic appearance </li></ul><ul><li>Described as: </li></ul><ul><ul><li>Just snapped </li></ul></ul><ul><ul><li>Flipped out </li></ul></ul>
    19. 21. <ul><ul><li>Pressured, loud, incoherent speech </li></ul></ul><ul><ul><li>Screaming for no apparent reason </li></ul></ul><ul><ul><li>Talking to imaginary people </li></ul></ul><ul><ul><li>Grunting, guttural sounds </li></ul></ul><ul><ul><li>Irrational speech </li></ul></ul>
    20. 22. <ul><li>Pepper Spray Death </li></ul><ul><li>TASER Death </li></ul><ul><li>Hogtie Death </li></ul>Media Labels Death
    21. 23. Handled Correctly
    22. 24. Agitation & Exertion Hyperthermia Acidosis & Rhabdomyolysis “ TREAT THE TRIAD” Stimulate/Intoxication Triad
    23. 25. A New Approach Access Capture Control Restrain Sedate Transport Chart Plan
    24. 26. <ul><li>No medical research to verify sedation and/or chemical restraint is the best answer </li></ul><ul><li>Available options currently in use </li></ul><ul><ul><li>Valium (Diazepam) </li></ul></ul><ul><ul><li>Haldol (Haloperidol) </li></ul></ul><ul><ul><li>Versed (Midazolam) In use in two healthcare systems </li></ul></ul><ul><ul><li>Ketamine (Ketalar) In use in two healthcare systems </li></ul></ul><ul><li>Key – Administer enough to achieve sedation </li></ul>Sedation
    25. 27. <ul><li>At the 2007 IPICD Conference the </li></ul><ul><li>Miami-Dade program administrator </li></ul><ul><li>announced 37 incidents involving </li></ul><ul><li>patients displaying ED symptoms </li></ul><ul><li>Deputy Chief J. Gardner </li></ul><ul><li>Zero Deaths </li></ul>Sedation Results
    26. 28. <ul><li>Urgent and Immediate </li></ul><ul><li>Extra manpower needed </li></ul><ul><ul><li>Crew safety </li></ul></ul><ul><ul><li>Multiple treatments (CPR) </li></ul></ul><ul><ul><li>Police if transported with handcuffs </li></ul></ul>Transport
    27. 29. Is this Appropriate?
    28. 30. <ul><li>Monitor patient (Pulse, Rate, Respirations) </li></ul><ul><li>IV fluid administration (Normal Saline 0.09%) </li></ul><ul><ul><li>ED patients typically need 20 L in first 24 hrs </li></ul></ul><ul><ul><li>Consider using cooled fluids (60 degrees) </li></ul></ul><ul><li>Counter Acidosis – Raise ph level </li></ul><ul><ul><li>Controlling ventilation </li></ul></ul><ul><ul><li>Administering Bicarb </li></ul></ul><ul><ul><ul><li>IV Drip 50 Meq Bicarb/1000 ml NS rapid infusion </li></ul></ul></ul><ul><ul><ul><li>May repeat once </li></ul></ul></ul>Advanced Protocols
    29. 31. <ul><ul><li>Miami-Dade Fire/EMS Versed Sedation, Cooling and Bicarb </li></ul></ul><ul><ul><li>Nashville Fire/EMS Versed Sedation only </li></ul></ul><ul><ul><li>Champaign, Illinois Ketamine Sedation </li></ul></ul><ul><ul><li>Appleton, Wisconsin Haloperidol Sedation </li></ul></ul>Advanced Protocols in Use
    30. 32. <ul><li>Patients behavior prior to and after arrival of responders (police) </li></ul><ul><li>Capture, Control and Restraint techniques </li></ul><ul><ul><li>TASER deployment and probe removal </li></ul></ul><ul><ul><li>Handcuff vs Soft Restraints </li></ul></ul><ul><li>Treatments and Response </li></ul><ul><li>Details, Details, Details </li></ul>Document
    31. 33. <ul><li>Carefully review policies & procedures </li></ul><ul><li>Liability is important but should not be your number one priority </li></ul><ul><li>Excited Delirium is a MEDICAL EMERGENCY </li></ul><ul><li>Police and EMS need to train and work together in the management of Excited Delirium patients </li></ul>Summary
    32. 34. <ul><li> = </li></ul>
    33. 35. Any Questions? <ul><li>Presented by: </li></ul><ul><li>Jerry Staton </li></ul><ul><ul><li>Affordable Realistic Tactical Training </li></ul></ul><ul><ul><li>Senior Master TASER Instructor </li></ul></ul><ul><ul><li>In-custody Death Specialist </li></ul></ul>

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