Excited Delirium Syndrome
By Kane Guthrie
CCASE
STUDY
Inside ED
6 police/security struggling to restrain! Swearing obscenities, unable to reason
with! Incredibly diaphoretic, & hot to touch! Unable to do vitals! Given 15 mg IMI Midazalam no effect! 20 mins later still being restrained!
Then Stops resisting, quiet, not moving!
Resuscitation
Placed on monitor. In asystole. Given 40 mins standard ACLS. No ROSC!
COD: Excited Delirium
Syndrome
Excited Delirium Syndrome
1St documented case 150 years ago “Fever with Mania”
Around 250 deaths per year in USA Majority literature/cases – USA Not universally fatal
Recognised as a unique syndrome
Excited Delirium
The term excited delirium, a condition described as an individual totally out of
control, unable to be reasoned with or talk down, & possessing great feats of
strength is somewhat vague & ill defined; but is well known to any police officer,
paramedic, or emergency clinician.
Fason, C. & Schneider, G. (2009).
Recent Coroner’s Case
Excited Delirium syndrome The typical course of EDS patient
involves: Acute drug intoxication Hx of mental illness. Struggle with law enforcement. Require physical or noxious chemical control
measures. Sudden & unexpected death. Autopsy fails to reveal cause.
ACEP Excited delirium Taskforce (2009)
Who’s @ risk of death?
Males. Psychostimulant drugs use. Suspected/known psychiatric illness. Failure to respond to police. Unusual physical strength/stamina. Nudity/inappropriate clothing. Erratic/violent behaviour.
The PathO!
Complex & poorly understood.
Thought to be from:
Dysregulated dopamine transporters Elevated heat shock proteins Catecholamine surge Severe acidosis plays a role in
cardiovascular collapse.
Clinical Features
Tachypnea Tachycardia Hyperthermia Hypertension Acidosis Rhabdomyolysis
Blame it on the Taser!
Dubious reports of taser’s causing death. Circumstantial evidence only. Political & social gains would have us
thinking otherwise!
Bottom line: Excited delirium causes deathsNot: Taser’s, OC spray or being in custody!
Taser’s may save lives:
Stop the downward spiral of: Struggling to exhaustion Hyperthermia Acidosis Cardiac depression
By allowing: Gain control – provide
sedation/supportive care!
The approach in ED
The approach in ED
This is a time sensitive disease!
It’s both a: Behavioural emergency!
And a Medical emergency!
Screening for EDS (PRIORITY)
P: Psychological issues.R: Recent drug/alcohol use.I: Incoherent thought process.O: Off (taking clothes off) & sweating.R: Restraint to presence. I: Inanimate objects: violent to-ward
shinny or glass objects.T: Tough, unstoppable, superhuman
strength.Y: Yelling.
The approach in ED
No “chain of survival” “Chain of Disaster” – we are the last
link!
Team approach Nurse, Senior Dr, Security Monitored area Rapid sedation is the priority Use least restrictive restraint method
Restraint Techniques
Team sport Enough staff to control individual Avoid seclusion rooms Physical restraints till sedation
achieved
Avoid prone position Restraint Asphyxia Syndrome
Sedation
Needs to be prompt and rapid!1ST Line: Benzodiazepines (Midazolam)2ND Line: Antipsychotics (Droperidal) or
Ketamine3rd Line: Rapid Sequence intubationRoutes: IV (preferred), consider IN,IMI, IO
Supportive Care
Once sedation achieved: Check: Temp, BSL, CK, Lactate and
PH. 12 lead ECG
Hyperthermia (Temp >38.5 risk of MOF):
Actively cool, fluids
Rhabdomyolysis: Fluids, IDC.
Take Home Points
Behavioural & Medical Emergency! Identify patients at risk! Require rapid sedation & supportive
care for good outcome! Educate your colleagues/EMS/police
on EDS!
Questions
Thank-you