EMS Medicine Live!€¦ · EMS Medicine Live • Zoom – During presentation • Everyone will be...

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EMS Medicine Live!

WelcomeWelcome

Fourth EMS Webinar

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EMS Medicine Live!

• VisionVision– Community & Academic EMS Physician

Education• Information Sharing• Board Preparation

– Group involvementp• Meet and see our peers• Involve your unique experiences and skills

EMS Medicine Live!Course Directors

Ch i ti K t MD MPHChristian Knutsen, MD, MPH

Derek Cooney, MD

Brian Clemency, DO

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EMS Medicine Live

• ZoomZoom– During presentation

• Everyone will be muted• Chat questions to Knutsen to be answered either

during or at the end of the presentation• Raise hand virtually in chat window

– RecordingRecording• Upstate will record and post conferences online• You can record at your site also

EMS Medicine Live

• Zoom• Zoom– Questions

• Questions at the end– Unmute yourself to ask a question or

– Message Knutsen if you have a question and I’ll ask for questions in order.

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EMS Medicine Live

• Zoom• Zoom– Technical Problems?

• Message me if you have a suggestion.

• If you have a serious problem, email [email protected]

EMS Medicine Live

• Speaker• Speaker

Christian Knutsen

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Excited Delirium and Sudden In Custody Death

Christian Knutsen

Excited Delirium

• What ExD is not• What ExD is not– Not universally recognized condition

– Not a medical diagnosis

No ICD-9 code

AMA does not recognize

– Not a psychiatric diagnosis

No DSM V

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Excited Delirium

• What ExD is• What ExD is– Descriptive Syndrome

– Accepted by ACEP/ED physicians, medical examiners, EMS, Police, Press

– You know it when you see it

Excited Delirium

• Appleton police encounter Wisconsin• Appleton police encounter, Wisconsin

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Excited Delirium

Three Componentsp

• Delirium

• Psychomotor Agitation

• Physiologic Excitation

Excited Delirium

Clinical Findings:g• Agitated, Combative, Bizarre

• Pain Tolerance

• Super-Human Strength

• Hyperthermic, Sweating

• Naked

• Tachycardia, Tachypnea

• Hallucinations, ParanoiaHallucinations, Paranoia

• Attack objects

• Fight to exhaustion

• Police noncompliance

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Excited Delirium

• Hyperthermiayp

• Metabolic Acidosis

• Rhabdomyolysis

• Multisystem Organ Failure

Excited Delirium

Historyy• 1650 appears in British literature• 1849 Dr. Luther Bell (Bell’s Mania)

– “Acute exhaustive mania” – 75% mortality in institutionalized psychotic patients

• 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 “e cited deliri m” 18 of hich ere peoplein 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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Excited Delirium

EtiologyEtiology– Stimulant Abuse

– Psychiatric Disease

– Other

– Combination

Excited DeliriumEtiology

Traditional StimulantsTraditional Stimulants

• Cocaine

• PCP

• Methamphetamines

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Designer StimulantsDesigner Stimulants

• Synthetic Cathinones

• Synthetic Cannabinoids


Synthetic CathinonesSynthetic Cathinones

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Synthetic CathinonesSynthetic Cathinones


• Khat (Catha edulis)– Flowering Plant

– Native to East Africa and Arabian Peninsula

– Popular in Somalia, Yemen

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• Natural Cathinone• Natural Cathinone– Euphroia

– Alertness

– Hallucinations


• Synthetic Cathinone• Synthetic Cathinone– First Developed 1920s

• Methcathinone

– Medical Uses• Antidepressants?

A i S ?• Appetite Suppressants?

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• Synthetic Cathinone• Synthetic Cathinone– Medical Uses

• Bupropion (Wellbutrin, Zyban)– Antidepressant, Smoking Cessation


• Similar to ecstasy and amphetamines• Similar to ecstasy and amphetaminesMDMA, Ecstasy

Methylone

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Synthetic Cathinones


Synthetic CathinonesAuraBlack RobBlissBlizzardBloomBlue SilCharge Cloud 9DroneH i Ch li

Lovey DoveyLunar WaveMaddieMCATMeow MeowMonkey DustMTVOcean SnowPeeveP l W

ScarfaceSextasySnow LeopardStardustSuper CokeVanilla SkyWhite LightningWhite RushWhite LadyZHurricane Charlie

Ivory WavePurple WavePVRed Dove

Zoom


• Synthetic Cathinones• Synthetic Cathinones– Flakka

– Gravel

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SyntheticSynthetic Cannabinoids

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– THC Analogs

– K2 and Spice• Better High?

• Legal Ambiguity?



– THC Analogs

– K2 and Spice• Bag of plant material

• Sprayed with drug

• Labeled “Not For Human Consumption”

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Excited Delirium

• Recently in Syracuse…Recently in Syracuse…– Spike in synthetic

cannabinoids cases• ~15-20 patients per days• High agitated, combative• Straining Police, EMS,

ED staff

Synthetic cannabinoids– Synthetic cannabinoids mixed with synthetic cathinones?

Excited Delirium

• Type 1 • Type 2yp– Bradycardic– Mild Hypotension– Lethargic/Coma– Agitation with

stimulation– ±Seizures– 5-10 mg Versed

yp– Tachycardic– Hypertensive– Highly agitated– Highly combative– Large pupils– ±Seizures– High dose benzosg

– Intubation due to sedations and airway protection

High dose benzos– Intubation for patient

control

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Psychiatric DiseasePsychiatric Disease – Untreated exacerbation of illness

– New onset psychiatric illness

– Suddenly stopping psychiatric medications• Withdrawal Syndrome?

• CNS adaption of therapy?

• Reemergence of underlying disease


• Medical • TraumaMedical– Sepsis– Meningitis– Encephalitis– Diabetes– Other endocrine

St k

Trauma– Head injury– Hypoxia– Hypovolemia

• Toxicology– Stroke– Dementia– Medications

– Alcohol

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Excited DeliriumManagement

Principles of carePrinciples of care– Protect your team!

EMTs, paramedics, ED techs, nurses, residents, other providers, and yourself!

– Protect the patient

Facilitate rapid diagnosis and management

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RODEOSRODEOS• Restraint• Oxygen• Detrose• Examination (PE, EKG, etc)• Observation• Serial assessment


Physical restraintPhysical restraint – Temporizing

– Anything that doesn’t get tighter

– Multiple people as a team

– Back away if resources not available

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Chemical restraintChemical restraint – IV, IO, IM, IN, Blow Dart

– Options• Benzodiazepines

• Antipsychotics

K i• Ketamine


Chemical restraintChemical restraint – Intubation

• Indications– Significant coma, airway protection

– Unable to control with sedatives safely

– Escalating doses of sedatives

• Hyperventilation?

• High dose sedation

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• ExaminationExamination– Trauma?– EKG changes? Hyperkalemia, Long QTc– CMP, CK, Troponin

• Observation & Metabolize To FreedomAd i ivs. Admission

• Serial assessment


CoolingCooling– Follow core temperature

– Sedation helpful

– Paralysis? Continuous EEG?

– IVF

– Cooling Blanket, Fans

– Cold packs

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Prehospital CarePrehospital Care– Proper training

• Patient Recognition

• Coordination of Care

• Restraint Techniques

P t l– Proper protocols

– Proper online medical control


CNY EMS Regional ProtocolCNY EMS Regional Protocol– Required med control order for sedation

– Increased time from physical to chemical restraint

– Difficult communications with crew

– Two paramedics hurt in first 48 hours of our new Spike epidemic

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CNY EMS Regional ProtocolCNY EMS Regional Protocol– NYSOH BEMS granted CNYEMS

emergency protocol change

– Midazolam 10 mg IM or 5 mg IV as standing order.

Cl h i– Close chart review

Sudden In Custody Death

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Law Enforcement PerspectiveLaw Enforcement Perspective– Irrational and combative

persons

– Danger to self

– Danger to officers

– Danger to community

– Must be subdued


Law Enforcement PerspectiveLaw Enforcement PerspectiveMeans of control

– Compliance by command– Compliance by pain

• Battons• Joint Lock Maneuvers• OC SprayOC Spray

– Compliance by Taser– Compliance by group force

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Sudden In-Custody Death

• Progression• Progression– Excited Delirium Symptoms

– Significant Restraint

– Acute Dyspnea

– Suddenly Quiet

– Death (bradyasystole)


• HypothesesHypotheses – Catacholamine Surge and Drop– Hypokalemia – Cardiovascular Disoder

• Genetic – Long QT Syndrome• Drug Abuse Induced Heart DamageDrug Abuse Induced Heart Damage

– Brain Biochemically Damaged– Uncompensated Acidosis

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Hypothesis: Uncompensated Acidosis


Hypothesis: Uncompensated Acidosis

• Metabolic acidosis

• Compensatory alkalosis…


Hypothesis: Uncompensated AcidosisHypothesis: Uncompensated Acidosis

• if ventilation compromised…

• Respiratory acidosis or

Uncompensated metabolic acidosis

• Cardiovascular Collapse• Cardiovascular Collapse

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• SICD Prevention• SICD Prevention– Minimize struggle

– Patient monitor

– Early Involvement of EMS


• SICD Prevention• SICD Prevention– Cardiac Monitoring

– Watch Respirations

– Expect Decompensation

– Rapid Transport

– Early, effective CPR

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October 2005October 2005

Donald Lewis found by the side of the road by Officer Raymond Shaw

Sudden In-Custody Death4:45

St tStart

4:45.40

Into Road

4:50.45

Restraint Starts

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4:49.30

O t f R dOut of Road

4:49.50

Less Restraint

Sudden In-Custody Death4:51.00

H Ti St tHog Tie Starts

Increasing Restraints

4:51.15

Movement to improve restraint

4:51.30

Breathing

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N t B thiNot Breathing

4:51.58

Recognized Arrest

4:51.30

Pulse Check


RRescue Breathing Started

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4:53.45No pulse?No pulse?

4:54.30CPR started5:2

4:55.10SROC

4:55.30Breath slower?Breath slower?

4:50.00+Pulse


EMS iEMS arrives

4:59.30

CPR Started?

Quality?

5:00 Intubation

5:00.20 Ongoing Intubation

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Sudden In-Custody Death05:01

Still I t b tiStill Intubating

No CPR

5:01.22

Office Mental State

EMS Medicine LiveApril 2015

SummarySummary– Excited Delirium: Clinical Findings,

Etiologies, Management

– SICD: Progression, Hypotheses of Cause, T C P iTreatment, Case Presentation

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