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What a Trip! is a post over at EMS Outside Agitator. firetender discusses a video of Excited Delirium Syndrome (ExDS). Some people may think that this patient does not have excited delirium, because the patient is so cooperative. That is a mistake.
If EMS had this patient on the monitor, there would be a lot of artifact, but we should expect to see a very elevated heart rate. Probably over 120 beats per minute. The patient is not trying to harm anyone else, but his body is working so hard that he can be hurting himself. He is a danger to himself. If over 8% (one out of every dozen) of these patients die from excited delirium, he will probably not die.
Wait – looking at those numbers is misleading without putting the numbers in context.
The majority of lethal ExDS patients die shortly after a violent struggle. Severe acidosis appears to play a prominent role in lethal ExDS-associated cardiovascular collapse.[1]
We also do not know how much sedation will affect the outcome. We need some sort of studies comparing the outcomes of excited delirium patients who are not sedated with the outcomes of excited delirium patients who are sedated.
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While regular exercise is protective and youthful bodies can withstand more punishment, extreme stress can kill, and stress is most extreme near the end of a race.[2]
When the person is restrained, there is no end of the race. It is just fight against the restraints until there is no fight left.
The patient is vigorously struggling against the straps, even though he did cooperate and lie down when the officer asked him to. Just because he is not trying to hurt anyone does not mean that he is not struggling. This is a form of extreme exertion.
If you want to know what this is like, have someone strap you to a board. Then have them inject you with a large dose of epinephrine. Then you can try to get out by breaking the straps. Maybe you will not try very hard, but if you do put a lot of effort into this, you will quickly exhaust yourself. Maybe you will kill yourself. This is extreme exertion and the people involved are usually not in excellent physical shape.
I am just kidding about the epinephrine. While it would be one way to experience what the patients are experiencing, it is a really bad idea. Epinephrine might as well be a heart attack in a syringe.
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Maybe this is the rhythm –
Maybe this is the rhythm –
Maybe it is some other rhythm.
We don’t know.
We can’t tell.
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firetender has a video on his post, but there is a better video here. Unfortunately, I cannot embed it. This starts with the call to dispatch, then switches to video from the scene.
At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case. This is excellent communication and the right assessment.
What should EMS do for excited delirium?
Sedation.
What if that doesn’t work?
More sedation.
What if that doesn’t work?
Even more sedation until it does work or we run out of sedation.
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At 5:37 (of the linked video) someone mentions, We’ve got Narcan and Haldol, or he said We gave Narcan and Haldol. I did not hear any other mention of EMS medications at any point, but the narrators drown out a lot of what is said.
Naloxone (Narcan) will only make this patient worse. If I run out of sedative, I want to give him morphine or fentanyl until he is sedated or until I run out of sedating medication to give. Opioids do have a sedating effect. Naloxone is for respiratory depression – where is there any sign of respiratory depression?[3] If we give naloxone to these patients, we may kill them.
Was naloxone given or just mentioned?
I don’t know, but if naloxone was given, too much was given.
Was haloperidol (Haldol) given or just mentioned?
I don’t know, but if haloperidol was given, not enough was given.
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Here is a different example of excited delirium. This one was fatal. The patient was not attacking any of the police, he was only trying to keep from being restrained.
The treatment is sedation. Unfortunately, restraints generally need to be used to get the patient in a position where it is safe to give medication. A Taser is another way to stop the patient for long enough to get a lot of sedative into the patient.
Small doses kill, because they usually don’t even slow the patient down and may make the patient even more agitated. Yes, that is possible.
Excited delirium is a psychological and metabolic emergency. The metabolic emergency is what kills patients. This is not the time to try to get patients to tough it out the all-natural way.
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Footnotes:
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[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF
Updated link to PDF 7/23/2018.
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[2] Philly Runners’ Deaths Point to Dangers of Extreme Stress on the Body – Between 6% & 17% of sudden cardiac deaths are associated with exertion
JEMS.com
Kia Gregory and Don Sapatkin
The Philadelphia Inquirer
Tuesday, November 22, 2011
Article
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[3] Scopolamine Poisoning among Heroin Users — New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996
MMWR (Morbidity and Mortality Weekly Report).
Vol 45, No 22;457;
Free Full Text . . . . Free PDF
On March 16, 1995, eight persons were treated in the emergency department (ED) of a Bronx hospital for acute onset of agitation and hallucinations approximately 1 hour after “snorting” heroin. On physical examination, all these persons had clinical manifestations of anticholinergic toxicity (i.e., tachycardia, mild hypertension, dilated pupils, dry skin and mucous membranes, and diminished or absent bowel sounds); five had urinary retention. All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.
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Great stuff, as always.
Just a little food for thought… over the years, how many deaths caused by excited delirium have been attributed to other things? I’m willing to bet that there have been quite a few.
Dewayne,
Thank you.
I don’t know, but excited delirium is not easy to define.
Without an accurate incidence of excited delirium, it is difficult to determine how many deaths might be mistakenly attributed to some other cause, such as cocaine overdose.
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Excellent article, as always.
After watching the video, and having seen these patients over the years, my reaction was “What’s so funny?”
While we can sit here and laugh and smirk (and I did), the EMS personnel on the scene were unprofessional.
Many police departments are going to digital video to document scenes. If this patient had a poor outcome this video would have hung EMS out to dry.
Our department uses Ketamine, 4mg/kg, given IM. I have used it once and used two injection sites because I thought it was an awfully lot of fluid to give in one injection. The patient was out like a light in about 3 minutes.
We also are particular on where we take these patients. Dumping them at the trendy suburban hospital ER is not a good idea. Get them to a place (like a level I or II trauma center) that has experienced staff and a security force worthy of the name.
Jack Bode,
Thank you.
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I don’t think that the EMS personnel were the ones laughing. The commentators were the ones laughing.
On the other hand, they could have done a better job of sedating him, assuming they did anything to sedate him. The police officer did a better job of calming the patient.
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There is a lot that is not clear from the video. Did EMS provide any treatment. I couldn’t tell. I did not see anything given. While the patient did not appear to become any more sedated during the video, that does not mean that nothing was given, only that whatever was given did not yet take effect, or was not given in a large enough dose, or both. Not giving anything falls into the not given in a large enough dose category.
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As I wrote in response to Bob Sullivan – Ketamine is interesting, but it is a stimulant, so it may not be a good idea with a patient having extreme sympathetic stimulation to begin with.
The results are what matter.
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This is true. It does seems that doctors in bust hospitals are quicker to sedate patients, rather than leave them fighting restraints and keeping their vital signs elevated.
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Hey Rogue,
Nice response. I believe that UK Paramedics have no option of chemically sedating patients. Also, have you heard EMCrits take on the art of human bondage?
http://flobach.com/2011/11/28/going-nuts/
flobach,
Thank you.
Yes, I have listened to the EMCrit podcast on sedation. There are many things to discuss about that podcast, so I have been covering some of the material I think is important to understand before covering the podcast. It is great to discuss after people have an understanding of the material. The diverse EMS services mean that we often do things very differently, and dealing with excited delirium is one thing on which there is little agreement.
This is one of the reasons I keep mentioning the ACEP White Paper on excited delirium (footnote number 1). This is a consensus document by emergency physicians – the people who deal with excited delirium. As Dr. Weingart points out, the excited patients psychiatrists deal with are those who have already been already medically cleared by the emergency physicians. Excited delirium is a medical emergency, not a psychiatric emergency. The appropriate guidelines for treatment should be coming from emergency medicine and from EMS, not from psychiatry.
I do need to provide some more research on why droperidol is more misunderstood than dangerous. Then I will address the EMCrit podcast. Podcast 060 – On Human Bondage and the Art of the Chemical Takedown.
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