Download - Ex ds expo 2011.handout
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Excited Delirium
Michael Dailey, MD FACEPEMS Medical Director
Hudson Mohawk Region NY
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My disclaimers:
No financial conflicts of interest
I am not a law enforcement officer – this is a physician’s perspective with deference and respect for my colleagues
There is no way to cover this concept in the time allowed, but let’s try
Opinions expressed are my own
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
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Perspective
Law enforcement• Safety of public, person of concern and LEO• Rapid control and restraint• Dangerous?
EMS• Diagnosis and treatment when called to patient• Risk from patient struggle• Risk from sharps if ECW deployed
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Who are we?
Emergency Medical Technicians
Paramedics
Physicians
Nurses
Firefighters
NOT cops – perspective here will not be law enforcement
Our part of care begins when patient is physically restrained
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Psychiatric calls and EMS
Can we restrain?
Can we protect ourselves?
Who is responsible for the well-being of the person trying to injure us?
We may have chemical restraint available, but how long does it take to work?
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Excited Delirium Syndrome = ExDS
Get excited about it, but keep each case boring and stay off the cover of the paper
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Excited Delirium Syndrome = ExDS
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Does ExDS Exist?
If I didn’t think so, we wouldn’t be here
People die in law enforcement custody. Some EMS may be able to help mitigate; some not…• Cardiomyopathy• Drug overdose/stimulant abuse• Metabolic acidosis• Positional restraint/asphyxia• Excited delirium
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Excited delerium
1650 appears in British literature
1849 Dr. Luther Bell (Bell’s Mania) described “acute exhaustive mania” inexplicable sudden death of psychotic
1985 Dr. Charles Wetli (Miami) coined “excited delirium” to explain sudden death associated with cocaine
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
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Where is ExDS not found?
AMA
ICD-9 Coding Manual
DSM-IV
Not a single diagnosis:
10-12 different diagnosis codes can apply
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DSM IV Criteria for Delirium
A. Disturbance of consciousness (i.e., reduced awareness about the environment) with less ability to focus, sustain, or shift attention.
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.
C. Develops over a short period of time (usually hours to days) and tends to fluctuate during the course of a day.
D. Evidence from the history, examination, or laboratory findings that
the disturbance is caused by direct physiologic consequences of a general medical condition.
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What is ExDS?
Delirium
Agitation
Combativeness
Unexpected strength
Elevated body temperature
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What do these people look like?
Psychological behavior
Communication behavior
Physical behavior
Physical exam characteristics
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Phases of the syndrome
Delirium with agitation
Sweating or appearance of high body temperature
Acquiescence (Not mentioned in all sources)
Respiratory compromise with potential respiratory arrest
Cardiac arrest
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General Rule: Medical versus psychiatric
Consider all potential medical causes before pronouncing behavior either “just alcohol” or “just psychiatric”
Danger to providers does not decrease based on etiology
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Undifferentiated agitation
Cocaine
Methamphetamine
Head trauma
Intox (beer muscles)
EtOH withdrawal
Psych
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Can you tell the difference?
Psychiatric agitation
Sympathomimetic intoxication• Cocaine or methamphetamine
Alcohol• Withdrawal or intoxication
Hypoglycemia
Head injury
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Another disclaimer…
I hate mnemonics!
“I WATCH DEATH” – causes of delirium
“TODS TIPS” – causes of altered mental status
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“I WATCH DEATH”
I = Infection
W = Withdrawal from drugs
A = Acute metabolic disorders
T = Trauma
C = CNS pathology
H = Hypoxia
D = Deficiency in vitamins
E = Endocrinopathy
A = Acute vascular insult
T = Toxins
H = Heavy metals
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TODS TIPS
T = Trauma, Acute head trauma
O = Organ Failure, Cardiopulmonary, Renal, Neurologic, Hematologic, Endocrine
D = Drugs
S = Structural, Chronic subdural, Intracranial aneurysm, hydrocephalus, neoplasm or abscess
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TODS TIPS
T = Toxins, Plants, CO, Heavy metals, Industrials
I = Infections, Sepsis, Meningitis, encephalitis, 3° syphilis, PNA, RMSF, etc
P = Psychiatric, Thought disorders, Mood disorder
S = Substrate Deficiency, Anoxia/hypoxia, Hypoglycemia, Wernicke-Korsakoff's (thiamine), Pellagra (niacin), Folic acid, Vitamin B12
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Drugs (think “the anti’s”)
• Antibiotics• Anticholinergics• Anticonvulsants• Antidepressants• Antiemetics• Antihypertensives =
Clonidine, Propranolol, • Anti-inflammatory =
Cyclosporin, NSAID, Steroid, Salicylate
• Antineoplastics = Methotrexate
• Antiparkinsonian = Levodopa
• Antipsychotics• Anti-cold = Antihistamine• Antiobesity• Other = Cimetidine,
Thyroid hormones, Theophylline, Iron
• Drugs of abuse
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Physiology of ExDS
Similar to Neuroleptic Malignant Syndrome
Hyper-excited Dopaminergic neurotransmitters
Increased firing of neurons leads to:• Increased muscular activity• Increased agitation• Increased movement• Reduced cognition• Reduced thermoregulatory ability
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Physiology
Stimulant abuse
Hyperexcited dopaminergic neurons
Metabolic acidosis
Respiratory acidosis
Hyperthermia
Ultimately…
Cascade or perfect storm• All of the above combine for a disaster
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Response to Excited Delirium
Increased muscular activity leads to:• Increased temperature• Increased BP• Increased HR
Increased metabolic activity leads to:• Increased lactic acid• Increased RR to blow off carbon dioxide
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Normal physiologic buffering
CO2 + H2O = HCO3- + H+
pH 7.4
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Normal exertional buffering
CO2 + H2O = HCO3- + H+
RR pH nl
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Drug induced exertional buffering
CO2 + H2O = HCO3- + H+
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Chest compression exertional buffering
RR pH
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So what do the AHA guidelines say?
Epi?
Amiodarone?
Lidocaine?
Shock?
Why 2 minutes of CPR?
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What do I do?
I am a physician—I write protocols…
Remember AHA ACLS is a guideline
Created by committee
Evidence based
Consensus of experts when no evidence
NO evidence in this case
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Lewis case from Palm Beach
Horrible case: COPS was riding along
I found this video on YouTube, but no clean copy
http://blogs.browardpalmbeach.com/juice/2009/03/police_and_city_of_wpb_off_the.php
http://www.wpbf.com/news/10547880/detail.html
My sympathy to the officers and the Lewis family
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What should we do?
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LEO Perspective
“Leave me alone so I can do my job”
“Doc, don’t give me shit, you don’t know what it is like out there”
“This guy was just beating me up, so I’m not giving him an inch”
“Oh, shoot, you mean you aren’t going to get me in trouble…”
“Oh, this is to protect me…”
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EMS Perspective
Patient in custody is struggling• How much is too much
Sedation• When to give mild sedation• When to give high doses of sedation
Should we check temperatures
Acute deterioration• Should we give bicarb?
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Principles of care in delirium
Protect the staff
Protect the person / patient
Facilitate rapid diagnosis and management
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Consequences
Rapid death• Positional asphyxia• Arrhythmias
Hyperthermic death
Untreated illness and morbidity
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RODEOS
Restraint
Oxygen
Detrose
Examination (PE, EKG, etc)
Observation
Serial assessment
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Restraint
Physical restraint is temporizing
Follow with medication / chemical restraint ASAP
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Restraints
Anything that doesn’t get tighter
Multiple people as a team
Back away if resources not available
Follow physical with chemical – not medically prudent to allow struggle
Systematic review of assessment measures and pharmacologic treatment
Clinical therapeutics
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Control goals
Understand drugs and understand what is happening with the human being
Principle very sick, may need IV
IM vs IV vs blowdart
What should endpoint be? • Sedation? • Or checking VS?• Checking blood sugar?
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Choose the right drug
Psychiatric or emotional cause• Antipsychotic• Withdrawal or sympathomimetic• Benzodiazepine• Unknown• Benzodiazepine
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Dopamine and delirium
Dopamine pathways are implicated
Chronic cocaine up-regulates dopamine receptors
Cocaine and other sympathomimetics release dopamine as a neurotransmitter
Turning up the heat…
Need to “turn down” the neurotransmitters
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Why benzodiazepines?
Enhance GABA
GABA (Y-aminobutyric acid) is an inhibitory neurotransmitter that reduces dopamine release
Increase GABA, decrease dopamine; thus, excitement is decreased
Turns on the AC…
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Benzodiazepines
Limited resp depression • But potential obstructive problem if flat on back• …unless alcohol involved then potential problem
BEWARE supplemental oxygen • how low can they go…• watch ventilatory status
Midazolam has most rapid onset of action IM or IN
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What about the old…5 and 2?
Haloperidol 5 mg mixed with
Lorazepam 2 mg
Single syringe IM
Is it really that bad?
“This cocktail proves you understand neither pharmacology, nor physiology”
Bob Hoffman, MD FACEP, FACET, Director NYC Poison Control Center
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Haloperidol - Haldol
Anticholinergic, so it actually decreases ability to thermoregulate
Decreases seizure threshold
Black box for QT prolongation
Not faster than benzodiazepines
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Now what?
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What if they go into cardiac arrest?
Uninterrupted compressions
PEA• Sodium bicarbonate – 2 amps
Asystole• Sodium bicarbonate – 2 amps
Ventricular fibrillation• Sodium bicarbonate – 2 amps• Hold on initial shock for 2 minutes• Hold on initial epinephrine
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Who dies in custody without trauma?
97% between 34 – 44
11% chemical spray
8% impact weapons
27% ECD weapons
63% struggle with LEO
53% ingested street drugs
60% exhibited bizarre behavior• Jeff Ho, Policemag, Aug 2005
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Recognition
Any case that begins as bizarre presentation
Another “EDP” call
An “assist the police”
Intox or drugged up
Naked patients should always be a significant concern…
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Take home message
If everything goes well, these calls are boring
If all goes badly reach for bicarb first
Prevention is key, work with law enforcement
Early chemical restraint is the key to safety
Safest agents are benzos, but use them safely—constant monitoring
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