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What is it? How do we diagnose it? How do we treat it?. E. D. Excited Delirium. E.D. is more then just agitation . Think Excited Delirium When Patient Displays:. Sudden Bizarre Behavior Hyperactivity Combativeness Super-Human Strength Paranoid Delusions Shouting Hallucinations

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What is it how do we diagnose it how do we treat it l.jpg

What is it?How do we diagnose it?How do we treat it?

E. D.

Excited Delirium



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Think Excited Delirium When Patient Displays:

Sudden Bizarre Behavior

Hyperactivity

Combativeness

Super-Human Strength

Paranoid Delusions

Shouting

Hallucinations

Hyperthermia


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Signs of Excited Delirium

Inability to Concentrate

Extreme Restlessness

Inability to remain still

Flailing

Diaphoresis

Flushed skin

Extreme Tachycardia

Shedding of clothes

Attraction to glass windows or mirrors


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Statistically Speaking

Summer Months

High Heat and Humidity

High Body Mass Index

Stimulant Use


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What causes Death in Excited Delirium?

Positional Asphyxia is frequently blamed and it is the most common position patients are in before they suddenly die.

Patients are usually Hogtied or Hobbled their hands tied behind their back to legs

This position makes it difficult for the chest wall to expand and for the diaphragm to contract. Thus breathing is difficult.


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Positional Asphyxia

Restraint Asphyxia

Involves Take down of violent Individual

Arms are held behind the back

Chest is frequently compressed

Force on chest prevents Chest wall excursion for breathing



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Why Does This Happen?

These patients are violent and are forcibly restrained by multiple police officers and end up prone on the ground with multiple people leaning or laying on them to stop their combative behavior !


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Stats on Positional asphyxia

LA County 216 Cases of Hobble Restraint Patient Deaths in 2005 retrospective study.

-Majority Found Prone by EMS

-All had struggled with the Police

-All had developed labored breathing

-All had unanticipated sudden cardiac arrest

- None Survived


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Hobble Position

Hobble Position as a cause of death is considered “controversial”.

Effects of position on healthy volunteers in inconclusive

Healthy volunteers had decreased pulmonary function values, but no hypoxia


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Pathophysiology

What Do We know about the Pathophysiology of Sudden Death in Excited Delirium ?


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Lactate

These patients are struggling, agitated, flailing and have tremendous muscle activity which produces large amounts of lactic acid, which results in….

Severe Metabolic Acidosis


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Rhabdomyolysis

Muscle Cells disintegrate

Release toxic components and electrolytes

Further alter acid base balance

Contribute to dangerous electrolyte imbalances


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Hyperkalemia

Released from inside muscle cells

Can cause cardiac dysrhythmias

These dysrhythmias can lead to death


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Hyperthermia

These patients have been shown to have temperatures of 106 degrees !

No wonder they are frequently found naked or shedding their clothes.

The temperature alone could them combative and irrational.


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HypoxiaThe last nail in the coffin?

Mix together stimulant use, acidosis, electrolyte disturbances like hyperkalemia, Rhabdomyolysis, hyperthermia and add hypoxia and you get… sudden death?


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Underlying Medical Conditions

Things which place the patient at increased risk of E.D. and sudden death with exertion:

Cardiac Disease

Lung Disease

Psychiatric Conditions with mania or psychosis

Stimulant Use or Abuse


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Management of Excited Delirium

Assess for treatable causes hypoglycemia and hypoxia

Restrain

Sedation

Cooling

Empiric Treatment for Metabolic Acidosis

Rehydration


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Assess for Treatable Causes

Hypoglycemia

Hypoxia

Hyperthermia


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Restraint

Physical

The patient must be restrained first, so you don’t get hurt and they don’t hurt themselves!

Chemical

The goal is chemical restraint to stop the cascade of struggle, and metabolic deterioration which leads to death !


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Sedation !

Benzodiazepines are most useful, large doses well tolerated; Ativan & Versed.

Haldol and Droperidol are not recommended due to high risk of EPS-

Extra pyramidal Syndrome causing uncontrolled muscle activity and speeding up the metabolic spiral towards death, and prolongation of QTc causing sudden death.


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How to Give Sedation

P.O. – Nope

I.M. - Okay

I.V. - Okay but risky

I.O. –Okay but dangerous

P.R.- Stinky and Slow

I.N.- Okay


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I.M. , I.V. or I.N.

IM intramuscular route preferred.

IV intravenous okay if it can be done safely, i.e. for the patient and the provider.

IN intranasal is another route being used by some agencies.


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Cooling

Cooling is critical

IV Fluids

Limit Activity

Ice Packs Groin and axilla


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Hypoglycemia

Hypoglycemia must be watched for and treated as a cause of delirium and a complication of continued agitation


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Dehydration

These patients are hot, sweaty and have extreme physical activity.

IV hydration helps everything in their metabolic crisis, acidosis, dehydration, hyperkalemia and Rhabdomyolysis.


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Hyperkalemia

IV Fluids

Bicarbonate

Dextrose

Insulin


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Miami Dade Protocol: Excited Delirium E.D.

Police contact EMS if:

Patient tasered by Police who fits E.D. criterion

Then Patient is:

Restrained by Police and then EMS takes over

Sedation with Nasal Versed then IV Versed

IV Bolus 2 liters of cold saline

Sodium Bicarbonate

Transport to ER with heads up call I..e E.D. Patient enroute


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The 2nd Annual Sudden Death, Excited Delirium & In-Custody Death Conference

Conference focusing upon the latest medical research findings, theories, and legal issues about excited delirium, sudden death, electronic control devices, and jail suicide, which are of great concern for law enforcement agencies around the world, will be held on November 28-30, 2007 at the Imperial Palace® Hotel, Las Vegas, Nevada. The three-day Conference is sponsored by the Institute for the Prevention of In-Custody Deaths.


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