This document describes a case of excited delirium syndrome (EDS) and provides information about the condition. A man experiencing EDS required 6 people to restrain him and was unresponsive to sedation. He later went into asystole and died despite resuscitation efforts. EDS is characterized by acute agitation, exceptional strength, and hyperthermia. It can be triggered by drug use or mental illness and often involves interactions with law enforcement. Rapid sedation is critical to changing the downward trajectory and preventing fatal complications like cardiac arrest.

2. CCASESTUDY

5.  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!

6.  Placed on monitor.
 In asystole.
 Given 40 mins standard ACLS.
 No ROSC!

7. COD: ExcitedDeliriumSyndrome

8.  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

9.  The term excited delirium, a condition
described as an individual totally out of
control, unable to be reasoned with or talk
down, & 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).

11.  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)

12.  Males.
 Psychostimulant drugs use.
 Suspected/known psychiatric illness.
 Failure to respond to police.
 Unusual physical strength/stamina.
 Nudity/inappropriate clothing.
 Erratic/violent behaviour.

13.  Complex & poorly understood.
Thought to be from:
 Dysregulated dopamine transporters
 Elevated heat shock proteins
 Catecholamine surge
 Severe acidosis plays a role in cardiovascular
collapse.

14.  Tachypnea
 Tachycardia
 Hyperthermia
 Hypertension
 Acidosis
 Rhabdomyolysis

15.  Dubious reports of taser’s causing death.
 Circumstantial evidence only.
 Political & social gains would have us thinking
otherwise!
Bottom line:
 Excited delirium causes deaths
Not:
 Taser’s, OC spray or being in custody!

16.  Stop the downward spiral of:
 Struggling to exhaustion
 Hyperthermia
 Acidosis
 Cardiac depression
By allowing:
 Gain control – provide sedation/supportive
care!

18.  This is a time sensitive disease!
It’s both a:
 Behavioural emergency!
And a
 Medical emergency!

19. 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.

20.  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

21.  Team sport
 Enough staff to control individual
 Avoid seclusion rooms
 Physical restraints till sedation achieved
 Avoid prone position
 Restraint Asphyxia Syndrome

22.  Needs to be prompt and rapid!
1ST Line:
 Benzodiazepines (Midazolam)
2ND Line:
 Antipsychotics (Droperidal) or Ketamine
3rd Line:
 Rapid Sequence intubation
Routes:
 IV (preferred), consider IN,IMI, IO

23. Once sedation achieved:
 Check: Temp, BSL, CK, Lactate and PH.
 12 lead ECG
Hyperthermia (Temp >38.5 risk of MOF):
 Actively cool, fluids
Rhabdomyolysis:
 Fluids, IDC.

24.  Behavioural & Medical Emergency!
 Identify patients at risk!
 Require rapid sedation & supportive care for
good outcome!
 Educate your colleagues/EMS/police on EDS!

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