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

kaneguthrie@gmail.com