4/28/2015

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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.

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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Reference

DeBard, Et. Al, ACEP Excited Delirium Task

Force. White Paper Report on Excited Delirium

Syndrome. September 2009.

Thanks