Presentation to ICEN 2012 on Excited Delirium Syndrome

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!

26. kaneguthrie@gmail.com