Excited Delirium

Michael Dailey, MD FACEPEMS Medical Director

Hudson Mohawk Region NY

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

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

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

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?

Excited Delirium Syndrome = ExDS

Get excited about it, but keep each case boring and stay off the cover of the paper

Excited Delirium Syndrome = ExDS

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

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

Where is ExDS not found?

AMA

ICD-9 Coding Manual

DSM-IV

Not a single diagnosis:

10-12 different diagnosis codes can apply

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.

What is ExDS?

Delirium

Agitation

Combativeness

Unexpected strength

Elevated body temperature

What do these people look like?

Psychological behavior

Communication behavior

Physical behavior

Physical exam characteristics

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

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

Undifferentiated agitation

Cocaine

Methamphetamine

Head trauma

Intox (beer muscles)

EtOH withdrawal

Psych

Can you tell the difference?

Psychiatric agitation

Sympathomimetic intoxication• Cocaine or methamphetamine

Alcohol• Withdrawal or intoxication

Hypoglycemia

Head injury

Another disclaimer…

I hate mnemonics!

“I WATCH DEATH” – causes of delirium

“TODS TIPS” – causes of altered mental status

“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

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

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

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

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

Physiology

Stimulant abuse

Hyperexcited dopaminergic neurons

Metabolic acidosis

Respiratory acidosis

Hyperthermia

Ultimately…

Cascade or perfect storm• All of the above combine for a disaster

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

Normal physiologic buffering

CO2 + H2O = HCO3- + H+

pH 7.4

Normal exertional buffering

CO2 + H2O = HCO3- + H+

RR pH nl

Drug induced exertional buffering

CO2 + H2O = HCO3- + H+

Chest compression exertional buffering

RR pH

So what do the AHA guidelines say?

Epi?

Amiodarone?

Lidocaine?

Shock?

Why 2 minutes of CPR?

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

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

What should we do?

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…”

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?

Principles of care in delirium

Protect the staff

Protect the person / patient

Facilitate rapid diagnosis and management

Consequences

Rapid death• Positional asphyxia• Arrhythmias

Hyperthermic death

Untreated illness and morbidity

RODEOS

Restraint

Oxygen

Detrose

Examination (PE, EKG, etc)

Observation

Serial assessment

Restraint

Physical restraint is temporizing

Follow with medication / chemical restraint ASAP

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

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?

Choose the right drug

Psychiatric or emotional cause• Antipsychotic• Withdrawal or sympathomimetic• Benzodiazepine• Unknown• Benzodiazepine

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

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…

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

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

Haloperidol - Haldol

Anticholinergic, so it actually decreases ability to thermoregulate

Decreases seizure threshold

Black box for QT prolongation

Not faster than benzodiazepines

Now what?

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

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

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…

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

Thank you.

Questions, thoughts or comments:

mwd101@gmail.com