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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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Sudden Bizarre Behavior
Inability to Concentrate
Inability to remain still
Shedding of clothes
Attraction to glass windows or mirrors
High Heat and Humidity
High Body Mass Index
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.
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
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 !
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
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
What Do We know about the Pathophysiology of Sudden Death in Excited Delirium ?
These patients are struggling, agitated, flailing and have tremendous muscle activity which produces large amounts of lactic acid, which results in….
Severe Metabolic Acidosis
Muscle Cells disintegrate
Release toxic components and electrolytes
Further alter acid base balance
Contribute to dangerous electrolyte imbalances
Released from inside muscle cells
Can cause cardiac dysrhythmias
These dysrhythmias can lead to death
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.
Mix together stimulant use, acidosis, electrolyte disturbances like hyperkalemia, Rhabdomyolysis, hyperthermia and add hypoxia and you get… sudden death?
Things which place the patient at increased risk of E.D. and sudden death with exertion:
Psychiatric Conditions with mania or psychosis
Stimulant Use or Abuse
Assess for treatable causes hypoglycemia and hypoxia
Empiric Treatment for Metabolic Acidosis
The patient must be restrained first, so you don’t get hurt and they don’t hurt themselves!
The goal is chemical restraint to stop the cascade of struggle, and metabolic deterioration which leads to death !
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.
P.O. – Nope
I.M. - Okay
I.V. - Okay but risky
I.O. –Okay but dangerous
P.R.- Stinky and Slow
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.
Cooling is critical
Ice Packs Groin and axilla
Hypoglycemia must be watched for and treated as a cause of delirium and a complication of continued agitation
These patients are hot, sweaty and have extreme physical activity.
IV hydration helps everything in their metabolic crisis, acidosis, dehydration, hyperkalemia and Rhabdomyolysis.
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
Transport to ER with heads up call I..e E.D. Patient enroute
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.