Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Excited Delirium, Sedation, and Comments – Part I

It isn’t my birthday. Still, Shane decided to provide me with plenty of giggles in his response to ‘Hog-tying’ death report faults Fla. medics.

Shane wrote –

I think you might want to review your comments and think before making some statements.

I already made the statements, so I cannot review the statements again before making those statement, unless I repeat the same statements. Based on what you wrote, I will have to repeat some comments. I should probably strengthen, and add to, other comments, because you do not appear to understand.

At first, I thought this comment was a joke. After thinking about it for a while, I suspect that you work for the QA/QI/CYA department of an EMS agency (or maybe you are an absentee medical director). Those are positions that seem to be filled with the most blatant promoters of misinformation. You comment is full of misinformation.

99% of the time, Chemical Sedation is NOT a good practice or recommended to control your patient.

According to whom?

Based on what?

You make bold statements, but you do not provide anything, not even a note from your kindergarten teacher, to support your uninformed assertion.

There are many underlying factors to consider, as you should know, and there are a reason hospitals, medical units and such carry leather restraints and other such devices including police handcuffs with an officer accompanying you in the truck.

There is no requirement for leather restraints on my ambulance, but my state medical director has written protocols with a variety of options for sedation for excited delirium.

By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.

By protecting my patient, I am protecting everyone else, too.

Please explain the justification for the legal advice that you are giving. Did you stay at a Holiday Inn Express last night?

You should be a patient advocate,

I am being a patient advocate.

You are advocating putting the employer and the medic first, because of some imaginary legal risk.

this does not mean “knocking them out” to better control them. Unknown medical history, allergies, head trauma… all these contribute and should be considered. By doing so could result in a medic induced code due to your actions to use drugs to control a patient.

We do not need to knock the patient out, but we do need to knock them down – we need to sedate excited delirium patients.

I provided a link to the ACEP White Paper. You should have used that opportunity to learn about excited delirium syndrome. Rather than learn, you decided to be an evangelist of ignorance. You wag your finger at me based on what?

You mention Unknown medical history, allergies, head trauma…. How would we make any of these better by increasing metabolic stress?

Fighting against restraints will only make the metabolic stress worse.

What do the experts state in that White Paper?

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]

ExDS is Excited Delirium Syndrome.

Acidosis is not going to get better with continued struggling, but sedation can stop the struggling. Leather restraints do not stop the struggling. Leather restraints do protect others, when secured correctly, but leather restraints also increase the danger to the patient.

ExDS subjects are known to be irrational, often violent and relatively impervious to pain.[1]

An irrational struggling acidotic patient is going to become less acidotic because . . . ?

An irrational struggling tachycardic patient is going to become less tachycardic because . . . ?

An irrational struggling hypertensive patient is going to become less hypertensive because . . . ?

An irrational struggling hyperthermic patient is going to become less hyperthermic because . . . ?

An irrational struggling hypoxic patient is going to become less hypoxic because . . . ?

Sedation decreases the struggling and decreases the cycle of worsening metabolism that the patient exacerbates by fighting against restraints.

Most authorities, including this Task Force, posit the beneficial use of aggressive chemical sedation as first line intervention. As with any critically ill patient, treatment should proceed concurrently with evaluation for precipitating causes or additional pathology.[1]

The experts do not agree with Shane’s fear of over-sedation.

The experts do not agree that the rest of the patient’s history is more important than sedation.

The experts appear to want to protect the patients with head injuries by sedating the patient.

The experts have thoroughly investigated the condition of excited delirium (something police, EMS, and emergency department staff are familiar with) and decided that use of aggressive chemical sedation as first line intervention is the right thing to do.

I think a little more thought should go into your blogs.

Clearly.

Footnotes:

[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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Comments

  1. “By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.”

    How… quaint.

    Don’t know what hospitals Shane is dealing with, but virtually every hospital I take patients to has virtually done away with leather restraints, partly because of Joint Commission requirements, but also because they’d much prefer to sedate.

    Let me repeat that: MUCH prefer to sedate.

    The last pair of leather restraints I saw used was close to 3 years ago. Now, they’ll use soft restraints only briefly, until the sedatives take hold, or leave the patient in the officer’s handcuffs if they were already in place, until the sedatives take hold.

    They have a long list of restrictions put in place by both their risk managers and TJC, detailing how/when hard leather restraints may be used. For most of them, they’d rather not detail someone to monitor the patient for 1:1 care, release one extremity, rotate every 2 hours, etc.

    They’d much rather use a B52, or Geodon, or Zyprexa, or increasingly, ketamine, and they’re tickled pink if we get a head start on that before we even arrive.

    The Borg allows us 10 mg of Versed by any route (IV, IN or IM) under standing orders for excited delirium patients, and then we must call for more. In my experience, requests for additional doses are almost never denied.

    I’d like to have ketamine, but when you’re speaking of adding a new drug to the formulary of 250+ ambulances, training and QA’ing 2000 medics to use it safely, it sometimes takes a while to get what you want.

  2. Great information and thank you for sharing the White Paper on ExDS. Will be using it to inservice our people on our new protocol for treatment of ExDS.

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