Psychostimulant (Amphetamines, Meth, PCP)Failure to respond reflects deliriumNudity related to hyperthermia
Excited delirium syndrome
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!
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)
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!