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Excited delirium syndrome


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Presentation to ICEN 2012 on Excited Delirium Syndrome

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Excited delirium syndrome

  2. 2.  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!
  3. 3.  Placed on monitor. In asystole. Given 40 mins standard ACLS. No ROSC!
  4. 4. COD: ExcitedDeliriumSyndrome
  5. 5.  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
  6. 6.  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).
  7. 7.  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)
  8. 8.  Males. Psychostimulant drugs use. Suspected/known psychiatric illness. Failure to respond to police. Unusual physical strength/stamina. Nudity/inappropriate clothing. Erratic/violent behaviour.
  9. 9.  Complex & poorly understood.Thought to be from: Dysregulated dopamine transporters Elevated heat shock proteins Catecholamine surge Severe acidosis plays a role in cardiovascular collapse.
  10. 10.  Tachypnea Tachycardia Hyperthermia Hypertension Acidosis Rhabdomyolysis
  11. 11.  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!
  12. 12.  Stop the downward spiral of:  Struggling to exhaustion  Hyperthermia  Acidosis  Cardiac depressionBy allowing: Gain control – provide sedation/supportive care!
  13. 13.  This is a time sensitive disease!It’s both a:  Behavioural emergency!And a  Medical emergency!
  14. 14. 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.
  15. 15.  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
  16. 16.  Team sport Enough staff to control individual Avoid seclusion rooms Physical restraints till sedation achieved Avoid prone position  Restraint Asphyxia Syndrome
  17. 17.  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
  18. 18. Once sedation achieved: Check: Temp, BSL, CK, Lactate and PH. 12 lead ECGHyperthermia (Temp >38.5 risk of MOF): Actively cool, fluidsRhabdomyolysis: Fluids, IDC.
  19. 19.  Behavioural & Medical Emergency! Identify patients at risk! Require rapid sedation & supportive care for good outcome! Educate your colleagues/EMS/police on EDS!
  20. 20.