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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.

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Ex ds expo 2011.handout

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