excited delirium -...
TRANSCRIPT
4/28/2015
1
Excited Delirium
Patrick Cody, DO, MPH, FACOEP
Norman Regional Health System
Objectives
Review the history of Excited Delirium
Syndrome (ExDS)
Understand the diagnostic features of this
disease
Review the treatment of ExDS
Case
A 22 year old male presents to the emergency
department via ambulance for a complaint of
anxiety. He admits to using methamphetamine
on a regular basis. His symptoms are vague and
non-specific. Basic labs are ordered, as well as
IV fluids and ativan. The nurse leaves the room
to get the medication, when he returns the
patient is missing from the room.
4/28/2015
2
Case (continued)
A short time later a crazy person is found
wandering the hospital property. He does not
follow commands presented to him by PD. He
is tased without results. He arrives via
ambulance. Several emergency personnel are
struggling with the patient when he arrives. PD
performs a lateral vascular restraint which is
followed by cardiopulmonary arrest.
Case conclusion
He is intubated and resuscitated after a short
time. Immediately following resuscitation his
pH is 6.7 (CO2 was normal 1 hr before), CK is
3500. After a prolonged ICU stay, he is
ultimately discharged to a nursing facility.
History
First described more than 150 years ago
Institutionalized patients
“Mentally disturbed”
Pharmacology lacking
4/28/2015
3
History
Luther Bell - McLean Asylum for the Insane (Massachusetts)
Bell’s mania
American Journal of Insanity
75% case fatality rate
Followed uncontrolled psychiatric illness
History
1950s
Drastic decline
Modern antipsychotic pharmaceutical therapy
Less institutionalization
1980s
Uptick
Associated with abuse of cocaine in North America
Cocaine, meth, pcp
“Excited Delirium” coined in 1985
Epidemiology
Incidence difficult to
determine
No standardized case
definition
Semantics in Coding
Diagnosis of exclusion on
autopsy
Little documentation
regarding survivors
4/28/2015
4
Autopsy case reports
95% fatalities are male
Mean age 36
Hyperaggressive, impervious to pain, combative,
hyperthermic, tachycardic
Struggle with law enforcement
Physical, noxious chemical, TASER use
Period of quiet followed by sudden death
Case reports (continued)
Most cases involve stimulant abuse
Cocaine most common
Other stimulants implicated
Psychiatric illness –smaller cohort
Abrupt cessation of psychotherapeutic drugs
Withdrawals?
Central nervous system adaptation?
Clinical Features
Feature Frequency (95% CI)
Pain tolerance 100 (83-100)
Tachypnea 100 (83-100)
Sweating 95 (75-100)
Agitation 95 (75-100)
Tactile Hyperthermia 95 (75-100)
Police noncompliance 90 (68-99)
Lack of tiring 90 (68-90)
Unusual strength 90 (68-90)
4/28/2015
5
Pathophysiology
Short story:
WE DON’T KNOW
More questions than answers
Mechanism of progression unknown
Risk factors for death unknown
Pathophysiology – What we DO
Know
Associations include:
Stimulant drug use
Psychiatric disease
Psychiatric medication withdrawl
Metabolic disorders
Cocaine
Levels usually less than OD
Similar to recreational drug users
Pathophysiology
Dopamine
Loss of dopamine transporter in the striatum
Hypothalamic dopamine receptors are responsible
for thermoregulation
Cardiac
Bradysystole
Ventricular dysrhythmias are rare
4/28/2015
6
Clinical Characteristics
Pathway not understood well
Described by epidemiology, usual course
Minimal required features to make diagnosis:
Delirium and excited or agitated state
Symptom cluster will vary
Different instigators
Death
Occurs Suddenly
Typically follows physical control measures
(remember our case)
Recurrent features
Male subjects
Avg age 36
Destructive or bizarre
behavior
Psychostimulant drug
intoxication
Psych illness history
Nudity or inappropriate
clothing
Failure to respond to PD
presence (delirium)
Erratic/violent behavior
Unusual strength and
stamina
Ongoing struggle
CV collapse following
struggle or after
quiescence
Inability to be resuscitated @
scene
4/28/2015
7
Ddx
Any:
Drug
Toxin
Extraneous substance
Any:
Psychiatric or medical conditions
Any:
Biochemical or physiologic alterations
DdX for Altered Mental Status
AEIOU TIPS
Alcohol
Endocrine, Encephalopathy, Electrolytes
Insulin (hypoglycemia)
Oxygen, Opiates (Other drugs)
Uremia
Toxins, Trauma, Temp
Infection
Psych
Stroke, Shock, SAH, Space occupying lesion
Mimickers of ExDS
Hypoglycemia
Violent outbursts, appearance of intoxication
FSBS solves the mystery
Heat Stroke
Tactile hyperthermia
Rhabdomyolysis
Delirium
May be associated with mental illness
4/28/2015
8
Mimickers of ExDS
Psychiatric Issues
Drug withdrawal or non-compliance
Substance abuse common in psych patients
Acute paranoid schizophrenia
Sudden Death Causes
Ischemic or drug induced
Stress cardiomyopathy
Long QT syndrome
Brugada syndrome
Cannon’s Voodoo death
Lethal Catatonia
Sudden unexplained death in epilepsy
Treatment
Recognition is key
Avoid physical control measures
Catecholamine surge
Metabolic acidosis
Safety Net
When safe
IV, O2, Monitors, FSBS
4/28/2015
9
Treatment
Agitation
Benzos, Antipsychotics, Ketamine
IV route preferred
May not be safe to involve needles (IN)
Doses are recommendations only
Lacking hard data
Benzos
Routes Dose
(mg)
Onset
(min)
Duration
(min)
Versed IN
IM
IV
5
5
2-5
3-5
10-15
3-5
30-60
120-360
30-60
Ativan IM
IV
4
2-4
15-30
2-5
60-120
15-60
Valium IM
IV
10
5-10
15-30
2-5
15-60
15-60
Antipsychotics
Route Dose
(mg)
Onset
(min)
Duration
(min)
Haldol IM
IV
10-20
5-10
15
10
180-360
180-360
Droperidol IM
IV
5
2.5
20
10
120-240
120-240
Geodon
(Ziprasidone)IM 10-20 10 240
Zyprexa
(Olanzapine)IM 10 15-30 24hrs
4/28/2015
10
Antipsychotics
Pitfalls:
Prolonged QTc
Risk for sudden cardiac death
Anticholinergic potentiation
Ketamine
Benefits:
Rapid onset
Lack of significant
CV/Resp effects
Pitfalls (rare):
Oral secretions
Laryngospasm
HTN
Emergence phenomenon
Route Dosing
(mg/kg)
Onset
(min)
Duration
(min)
IM 4-5 3-5 60-90
IV 2 1 20-30
RSI
Provider discretion
May be required to control the situation
4/28/2015
11
Hyperthermia
Passive
Removal from warm environment
Removal of clothes
Active
Misting
Evaporative cooling
Ice packs
Acidosis/ Rhabdomyolysis
IVF
Bicarb
Controversial
Efficacy unknown
Some EMS agencies use it empirically (rhabdo)
Try not to interfere with hyperventilation
Law Enforcement
Often Involved
Person with ExDS has deteriorated to the point PD
is called
Has to:
Recognize medical emergency
Attempt to control irrational and physically resistive
person
Keep everyone safe
4/28/2015
12
Law Enforcement
High Risk
Injury/death to the officer
ExDS subject has potentially lethal condition
Public Relations
Perfect outcomes expected
Public scrutiny of in-custody deaths
What should officers do?
Recognize that subjects:
Have an acute, life threatening medical condition
Lack understanding, normal fear, rational thoughts
Are violent and impervious to pain
What should officers do?
Traditional tactics WILL fail:
Pepper spray
Impact batons
Joint lock maneuvers
Punching, kicking
4/28/2015
13
What should officers do?
GOALS:
Recognize ExDS
Contain Subject
Quickly take into custody
Turn care over to EMS ASAP
Document temperature ASAP
To support that PD intervention was independent of
death
EMS
Goals:
Recognize ExDs
Request more officers
Have duty to provide timely care while maintaining
safety
Summary
Identification is important
Early intervention with sedation
Minimize physical stress
We don’t know who will die
Even when we do everything right…
Good documentation on our part
Help Researchers
High liability situation.
4/28/2015
14
Reference
DeBard, Et. Al, ACEP Excited Delirium Task
Force. White Paper Report on Excited Delirium
Syndrome. September 2009.
Thanks