Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Was the In-Custody Death of Eric Garner Due to Police and EMS Abuse? Part I


 

In NYC Medics Restricted By FDNY Pending Investigation Into NYPD Custody Death, The Social Medic writes about the death of Eric Garner during an arrest. Death may have many different causes. Is there any one thing that would have resulted in Eric Garner still being alive – if it had not been done (or if it had been done)?

We do not know.

We probably never will know.

Did Eric Garner deserve to die? No.

Was there a valid reason for an arrest? There is nothing in this video to answer that question.

Should the police have tried to take Eric Garner down the way they did?

Is that a real choke hold, or a movie of the week choke hold?

How much choking was going on?

How much resisting was going on?

The videos only show some of what was going on, but it seems like this was not well thought out.

Eric Garner is a big man and should be approached with a well coordinated plan for the safety of everyone – for the safety of Eric Garner, for the safety of the police, and for the safety of the bystanders. Was ESU (Emergency Services Unit) there? Was a Taser available and is Taser use permitted in that jurisdiction?

A Taser might have saved Eric Garner’s life, but Eric Garner still might have died, even if the police had not arrested him. Sudden death happens hundreds of thousands of times a year in America.

When the police initially take him down, they brush up against/bounce off of a window. If it is glass, what would have happened if it broke? If it is glass, what if they had continued through the glass? If it is not glass, how do they know?

The difference between broken glass and a knife (or a sword) is not in the amount of danger they present, since all can kill you very quickly. This difference is in the perception of that danger.
 

In this video, Eric Garner repeatedly states that he cannot breathe, but this is probably not the first time that police have heard similar statements while wrestling someone into custody. EMS was not there, so no treatment was immediately available, if any treatment had been indicated. We cannot tell. His death later is not proof that he was having trouble breathing, but it does suggest that he was not breathing adequately.
 

The video cannot be shown at the moment. Please try again later.


 

The commentary from the person filming the video is useless. It is just as prejudiced and uninformed as that of any other politically motivated commentary.

All he did was break up a fight?

Unlikely, but how would the person filming this know?

Prejudiced cops on Staten Island, this is what they do?

Does that applied to the non-white cops, too? Or is that just a prejudiced comment? Prejudice does exist. Nobody is immune from it, but what is the critic basing his comments on? He appears to be basing his comments on his prejudice.

Eric Garner was beat up?

He was violently subdued/wrestled to the ground, but I did not see anyone strike him.

Eric Garner was not beat up.

The critic seems to be singing along with the music in the background, which does not really give the impression of someone who thinks he is witnessing someone being killed. He makes a lot of accusations, but his actions do not match his words. If you are singing along with Muzak, you appear to be indicating that there is nothing important distracting you from your singing. Maybe it is someone next to the critic, but that still suggests that there was not a lot of concern among those as close to events as the critic.

Did the police choke Eric Garner into submission or did one officer overestimate the effect he would have on a much larger guy by grabbing him around the neck?

Someone has written, None of the officers knew what to do in this situation on the bottom of the video. What would the film critic like the police to do? Should they put Eric Garner in the back of a police car?

What does the film critic suggest that they do?

They have called for an ambulance and they have Eric Garner in the rescue position.

Did the police use an inappropriate method of arresting Eric Garner?

The prohibition on the use of a choke hold for restraint may have more to do with the way things look to bystanders, than the effect it has on the person being restrained. Choke holds are not prohibited in most combat sport because apparently choke holds can be used safely. Did the choke hold cause death?
 


Image credit – Wikipedia article on choke holds.
 

At about 4:30 of the video, EMS enters.

I have not commented on what The Social Medic wrote about this incident, yet. I will comment on what can be seen of what EMS did (did not do) and whether excited delirium is a part of this in Part II.

.

Would a Taser Have Made a Difference in the Outcome?


Investigators on the scene of a deadly shooting by San Mateo County Sheriff’s deputies. (CBS)
 

What kind of response should EMS have when a person is reported to be acting violently and carrying a knife? We stage around the corner, or a few blocks away.

What about the police? They need to try to disarm the person and control things without anyone getting hurt, but that is not always possible.

According to the various articles in the news, two deputies arrived and confronted Yanira Serrano-Garcia, an 18 year old woman who had not been taking her medication.
 

Two deputies responded to the Moonridge Housing Complex at Miramontes Point Road, east of Highway 1, where the woman lived, Rosenblatt said. The family told dispatchers the woman was mentally ill and was located down the block with a knife, and that she refused to put the weapon down when asked.[1]

 

However, another article states that the police were provided with different information.
 

The information received by emergency personnel who responded to the incident was that the woman was acting erratically and violently and had a knife. The woman’s family asked her to put the knife down, and when she didn’t comply, family members called the fire department for medical assistance, Rosenblatt said.[2]

 

Another states –
 

The family told dispatchers the woman was mentally ill and was located down the block with a knife, and that she refused to put the weapon down when asked.[3]

 

No recordings of 911 tapes are quoted, but the information that was provided to the responding deputies might change how they approached her.

Should the family have tried to get unarmed EMS to respond to care for a violent armed patient? No.

Were they just trying to protect her? Probably.

What happened?

The two deputies confronted Yanira Serrano-Garcia and shot her at least once. She was pronounced dead on scene.
 

“I don’t know why they couldn’t have done better things instead of getting a bullet through her and trying to shoot her,” said Saul Miramontes, Serrano-Garcia’s cousin. “She was kind of sick — you know, at least they could have Tasered her or at least tackled her.”[1]

 

Tackling someone who has a knife is a very bad idea for everyone. It had Darwin award written all over it.

A Taser may be appropriate, but it should involve at least two armed people, one with the Taser and one backup with a firearm that is drawn and aimed at the person to be taken down. It is not considered appropriate to just drive up and use the Taser without making some attempt to get the person to put down the knife voluntarily.

One problem with the use of the Taser is that if you are close enough to use the Taser, and the person with the knife lunges toward you, you may be stabbed without being able to hit the person with the Taser.
 


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher
 

Did either deputy have a Taser out? We do not know from any of the articles.

Why did only one deputy shoot? It may be that they were not positioned well and when the deputy who did shoot moved, he moved into the line of fire of the other deputy. Maybe the other deputy froze. Maybe the other deputy did not think that a shot was the appropriate response for the circumstances. There can be many other reasons. We do not know.

Was there some other reason that the deputy felt the need to shoot quickly (the shot is reported to have taken place within a minute of arriving on scene)?

There is another bit of information that has not been included in the more recent news reports. This is from a cached copy of one article.
 

Dyanna Ruiz, 12, said she had been walking to a friend’s house when she saw the deputy running away from a woman who had her arm raised and was chasing him with what appeared to be a knife.

“I saw the girl running at him with something in her hands,” Dyanna said. “I didn’t know what was happening. I was really scared about what to do.”

The deputy saw Dyanna, stopped and yelled at Serrano-Garcia, the girl said. When Serrano-Garcia kept coming at him, the deputy fired, Dyanna said.[4]

 

The deputies may have had a plan for controlling the situation that may have seemed reasonable with just the two of them and the person with the knife at risk. With a child/adolescent also at risk, the plan may fall apart. That is pure speculation on my part, but I have a lot of experience with plans falling apart, as does anyone who deals with emergencies.

Why was the statement of this witness removed from more recent versions of the article? I do not know.

Will a Taser always work? No. Sometimes, in spite of reasonable attempts to do everything right and protect lives, bad outcomes still happen.

Footnotes:

[1] Half Moon Bay woman, 18, fatally shot by deputy after lunging at him with knife, authorities say
By Erin Ivie eivie@mercurynews.com
Posted: 06/04/2014 05:56:45 AM PD Updated: 6 Days ago
Contra Costa Times News
Article

[2] Officer Who Killed Woman Felt His Life Was in Danger
Joan Dentler (BCN)
Friday June 06, 2014 – 09:51:00 AM
Page One
The Berkely Daily Planet
Article

[3] Half Moon Bay woman, 18, fatally shot by deputy after lunging at him with knife, authorities say
By Erin Ivie
eivie@mercurynews.com
Posted: 06/04/2014 05:56:22 AM PDT Updated: 6 Days ago
San Jose Mercury News
Article

[4] Woman, 18, shot dead by San Mateo sheriff’s deputy
Henry K. Lee and Kurtis Alexander
Updated 5:07 pm, Wednesday, June 4, 2014
SFGate.com
Cached version of the article. It is a snapshot of the page as it appeared on Jun 5, 2014 00:40:18 GMT.

Woman, 18, wielding knife shot dead by San Mateo deputy
Henry K. Lee and Kurtis Alexander
Updated 8:46 pm, Friday, June 6, 2014
Article at the same link, but when I last checked at 18:00 6/10/2014, the part I quoted was not in the article.

.

Face Down Restraint into a Pillow


 

This picture just shows one image from one direction at one instant. A 12 lead ECG provides much more data and many more perspectives.

but . . . .

What it appears to show raises some questions.
 

P is for pillow – best part of paramedic school.

The pillow may not completely obstruct the airway, but this is probably not part of their protocols.
 

The patient’s hands have a bit of a cyanotic appearance, but the ears do not, so I suspect that the hands are discolored due to wrist restraints, not the pillow airway maneuver.

Glove use is fantastic, although there is no apparent need for gloves, but Scene safety, BSI then airway?

Why is the patient is restrained? Probably some charm deficit.

The side of the ambulance has Advanced Life (and maybe Support outside of the image) written on the side, so they should have access to chemical restraints – charm in a syringe.

Are any medications being used for chemical restraint?

Have any medications been used for chemical restraint?

Do protocols allow for any chemical restraint?
 

If you do not think that chemical restraint is important – to protect us and to protect the patient – listen to the EMS EduCast Excited Delirium episode.[1]

After listening to the podcast, imagine how this picture might be used to persuade a jury that you are guilty of murder or negligent homicide.
 

And this is a good time to remind everyone that K is for ketamine – the fastest IM (IntraMuscular) chemical restraint drug we have (after succinylcholine [suxamethonium in Commonwealth countries]). Even laryngospasm should not produce more of an airway problem and laryngospasm is manageable.[2]
 

 

Since one of the reasons for chemical restraint is to protect the patient, since in custody deaths may be die to excited delirium, and restraint asphyxia is one possible cause, why is the airway apparently not being addressed more aggressively?

Only one person is holding a violent patient down?

If one person is capable of restraining the patient, all by himself and with just one knee, is that a good sign?

On the plus side – at least he isn’t hog tied.

Does anyone want to guess at the patient’s heart rate?

Maybe that is the next thing to be done. We cannot tell, but all we can do is guess at the heart rate.
 

The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress.[3]

 

Sedation is my friend.

Sedation is the patient’s friend.

If I cannot handle an overly sedated person, I should not be working in EMS.

Over-sedation (under-stimulation) is a small, but easy to manage problem.

Under-sedation (over-stimulation) is a big problem complicated by a failure to understand the relative risks.

Maybe this is the rhythm –
 


 

Maybe this is the rhythm –
 


 

Maybe it is some other rhythm.

We don’t know.

We can’t tell.
 

It’s all about the little things.

Airway?

Breathing?

Circulation?

All appear to be mysteries for this patient.

Face down restraint is a bad idea.

Obstructing the airway is a bad idea – even if the patient is spitting.
 

How’s that airway?

P is for pillow!
 

Footnotes:

[1] Excited Delirium: Episode 72 EMS EduCast
EMS EduCast
September 23, 2010
Web page with link to podcast

While on the topic of podcasts, Dr. Scott Weingart provides the view of the emergency physician on chemical restraint.

Podcast 060 – On Human Bondage and the Art of the Chemical Takedown
by EMCRIT
November 13, 2011
Podcast and page with research links

[2] Laryngospasm, hypoxia, excited delirium, and ketamine – Part I
Thu, 21 Jun 2012
Rogue Medic
Article

[3] Excited delirium, restraints, and unexpected death: a review of pathogenesis.
Otahbachi M, Cevik C, Bagdure S, Nugent K.
Am J Forensic Med Pathol. 2010 Jun;31(2):107-12. Review.
PMID: 20190633 [PubMed - indexed for MEDLINE]
 

Unexpected deaths periodically occur in individuals held in police custody. These decedents usually have had significant physical exertion associated with violent and/or bizarre behavior, have been restrained by the police, and often have drug intoxication. Autopsy material from these cases may not provide a satisfactory explanation for the cause of death, and these deaths are then attributed to the excited delirium syndrome. The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias. We suggest that these deaths are secondary to stress cardiomyopathy similar to the cardiomyopathy seen in older women following either mental or physical stress. This syndrome develops secondary to the toxic effects of high levels of catecholamines on either cardiac myocytes or on the coronary microvasculature. Patients with stress cardiomyopathy have unique ventricular morphology on echocardiograms and left ventricular angiography and have had normal coronary angiograms. People who die under unusual circumstances associated with high catecholamine levels have contraction bands in their myocardium. Consequently, the pathogenesis of the excited delirium syndrome could be evaluated by using echocardiograms in patients brought to the emergency centers, and by more careful assessment of the myocardium and coronary vessels at autopsy. Treatment should focus on prevention through the reduction of stress.

 

.

Mentally Ill Patient Escapes EMS and Sues for Injuries

 

A Bronx woman is suing police and emergency medical services providers for injuries that occurred when she escaped custody and ended up leaping from a third story window.[1]

 

What is our liability for the behavior of patients with behavioral problems?

What is our authority to control the behavior of patients with behavioral problems?

 

She has filed suit against the city, the ambulance service, and the police officers for not properly supervising and restraining her. She argues that she was clearly mentally ill and should have been immobilized for her own protection.[2]

 

While the police and EMS probably could not have predicted that she would jump from the third floor of the building if she escaped, that does make a pretty good case for her being off her rocker not being responsible for her actions. On the other hand, the LD50 for jumping from a building is 4 floors, so she did not jump from high enough to expect to die.
 

It’s unclear whether the officers called for an ambulance because Rodriguez suffered injuries from damaging the car or because they recognized that she might be mentally ill.[2]

 

We, and the police, are called to protect everyone else from patient like this, but we are also called to protect the patients from themselves.

Kelly Grayson just posted on Facebook about the difference between a couple of behavioral problem patients.
 

What’s more stressful than dealing with the violent, hulking behemoth with a tenuous cheese-cracker interface?

Dealing with the *potentially* violent, hulking behemoth with a tenuous cheese-cracker interface, that’s what.[3]

 


Image credit.
 

If they all looked like this, it would be easy to treat aggressively and avoid problems, but that is not the way many will present – especially after being restrained by police.

The article does not provide many details, but that is the essence of the problem Kelly is describing – these patients are unpredictable unknowns. Many will sit calmly and cooperate at all times. Others are just waiting for the opportunity to do something creative, which is not good for us.

These patients are the known unknowns, but their future behaviors are the unknown unknown.[4] Often, they do not even know what they are going to do.
 

I started out by asking –

What is our liability for the behavior of patients with behavioral problems?

That may be up to a jury. We also have to live with the adverse outcomes we could have prevented.
 

The responders erred in “not restraining or immobilizing [Rodriguez] to ensure that she was not capable of hurting herself” and were negligent in “allowing her to leave the ambulance without fully assessing her mental state,” the complaint states. It cites a line in Article 9 of the New York Mental Hygiene laws, which notes the “Powers of Certain Peace Officers and Police Officers to take into custody any persons who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others.”[2]

 

Interesting assertions, but we do not have anywhere near enough information to know if they are true. In Pennsylvania, I do not have the authority to involuntarily commit patients.

My preference is to sedate patients. Safer for everyone involved, including the techs, nurses, PAs, and doctors at the hospital.

What is our authority to control the behavior of patients with behavioral problems?

That is often up to the medical director – state, county, service – and the ability of the medical director to understand how unstable these patients can be.
 

I think this is a cautionary tale for all of us. We need to be aware of what our patients are doing once we have them in our care and should not leave them unattended in the back of an ambulance especially when perhaps they are mentally disturbed. I want to make it clear that I’m not second guessing these EMTs.[1]

 

There is a lot to discuss.

Footnotes:

[1] Mentally Ill Patient Escapes EMS and Sues for Injuries
By podmedic
August 2, 2013
MedicCast
Article

Social Media, EMS and Public Health on Episode 344
By podmedic
July 29, 2013
MedicCast
Article with link to podcast.

[2] Woman Sues EMTs, Police for Letting Her Leave Ambulance and Jump Out Apartment Window
By Albert Samaha
Tue., Jul. 16 2013 at 10:30 AM
The Village Voice Blogs
Article

[3] What’s more stressful than dealing with the violent, hulking behemoth with a tenuous cheese-cracker interface?
Facebook
Kelly Grayson
Post

[4] Secretary Rumsfeld Press Conference at NATO Headquarters, Brussels, Belgium
Secretary of Defense Donald H. Rumsfeld
June 06, 2002
Transcript

Q: Regarding terrorism and weapons of mass destruction, you said something to the effect that the real situation is worse than the facts show. I wonder if you could tell us what is worse than is generally understood.

Rumsfeld: Sure. All of us in this business read intelligence information. And we read it daily and we think about it and it becomes, in our minds, essentially what exists. And that’s wrong. It is not what exists.

Now what is the message there? The message is that there are no “knowns.” There are things we know that we know. There are known unknowns. That is to say there are things that we now know we don’t know. But there are also unknown unknowns. There are things we do not know we don’t know. So when we do the best we can and we pull all this information together, and we then say well that’s basically what we see as the situation, that is really only the known knowns and the known unknowns. And each year, we discover a few more of those unknown unknowns.

It sounds like a riddle. It isn’t a riddle. It is a very serious, important matter.

There’s another way to phrase that and that is that the absence of evidence is not evidence of absence. It is basically saying the same thing in a different way. Simply because you do not have evidence that something exists does not mean that you have evidence that it doesn’t exist. And yet almost always, when we make our threat assessments, when we look at the world, we end up basing it on the first two pieces of that puzzle, rather than all three.

.

Excited Delirium – Episode One of Rogue Medic Rants podcast

 

Matt Fults and Brad Buck are hosting a podcast for me at Standing Orders – The Podcast.

They share a delusions that there is not enough Rogue Medic on the internet. :???:

Their solution is to give me my own podcast on their site. :cool:

They mention that they are excited; I point out that they are delusional; so the first podcast is perhaps the best way to combine these into one diagnosis – Excited Delirium. :shock:
 

Episode One: Excited Delirium
 


 


Image credit.
 

Does anything suggest excited delirium as succinctly as that image?

No. That is not a picture of me.

I am putting all of the links on the Rogue Medic Rants page for each post. You can listen to the podcast and look up the links all from one page.

This podcast has almost ten minutes of introduction because it is the first one. Later podcasts will have much less of an introduction, or maybe no introduction.

After the introduction, the discussion of excited delirium is less than 15 minutes long.

I apologize for not being well prepared for the podcast. I had all of my notes set for a different podcast, but we decided that one will be done at a different time for a variety of reasons. I hope that I provided enough information in the notes to correct any inaccuracies in the podcast. I think the only one was the dose of ketamine – the starting dose should be 5 mg/kg, not 2 mg/kg. 2 mg/kg is great for procedural sedation, but not for taking down a violent patient.

I will try to keep the podcasts short.

I may have some longer podcasts with a guest, or with several guests. I have already invited Peter Canning of Street Watch: Notes of a Paramedic. He is currently doing an excellent series on What BLS Should Be Doing Now.

Matt, Brad, and I will be at Gathering of Eagles, so feel free to talk to anyone with a shirt with the Standing Orders logo on it. I don’t have one, so just look for someone who looks weird. :oops:

There will probably be some Standing Orders and/or Rogue Medic Rants podcasts from Gathering of Eagles. Not live, but probably without much of a delay.

One of the topics I really want to talk with the attendees about is the recent spinal immobilization research and research reviews, but that is a topic for some other posts.

Let me know what you think about the podcast. Ways to improve it – I am no Morgan Freeman, but I will try to make it easy to listen to.

Suggestions for topics and guests, further information on a podcast, and criticism – all are welcome.

Likewise, let Matt and Brad know what you think.
 

Rogue Medic Rants
 

.

Laryngospasm, hypoxia, excited delirium, and ketamine – Part II

ResearchBlogging.org

Continuing from Part I, where our excited delirium patient was sedated quickly with IM (IntraMuscular) ketamine, but developed laryngospasm and cyanosis later at the hospital.
 

Assisted ventilation was discontinued and the patient was able to maintain a patent airway.[1]

 

All better!

Actually, not remotely All better!
 

After several minutes, the patient again developed hypoxia, airway obstruction, and spasms of the larynx.[1]

 


Laryngospasm image credit.
 

Do we have a good drug to prevent laryngospasm?

Can we ventilate him again? Yes, but there is a bit of a pattern developing. It would not be good to ignore the possibility that there may be more episodes of laryngospasm for this patient today.
 

Positive-pressure ventilation was again able to overcome the obstruction; however, given the recurrent nature of the laryngospasm, the trachea was intubated after the administration of succinycholine.[1]

 

No recreational drugs were found on the drug screen, but he did have an alcohol level of 220 (0.22 mg/dL). It is a mistake to think that excited delirium is always about illegal drugs.

No cocaine, no amphetamines, no PCP, not even bath salts. Just good old legal alcohol. Not even a huge dose of alcohol, but in that sweet spot between clearly drunk and unable to protect his own airway. How much of the alcohol did he burn off in the fight with police before the alcohol level was obtained?
 

Given the recurrent nature of the larygnospasm, our patient was ultimately intubated to decrease the risk of respiratory arrest during transport out of the ED for head CT. In contrast, during EMS transport, patients are not separated from the EMS provider until care is transferred at the receiving ED. The constant attendance to the patient by EMS providers allows for immediate and, if necessary, repeated assisted ventilation. Restricting ketamine to EMS units capable of rapid-sequence intubation therefore seems unnecessary.[1]

 

It is nice to see people acknowledge this difference between EMS and in-hospital care. With competent EMS personnel, we are almost never more than arm’s length away from the patient. A failure to recognize a problem with respirations is rarely possible with competent personnel. We should also never be allowed to intubate until after we have demonstrated competence with a BVM (Bag Valve Mask) and we should maintain that competence. Regular experience is important.
 

Providers should be educated to vigilantly monitor for hypoventilation. The use of end-tidal carbon dioxide measurement and pulse oximetry should be routine.[1]

 

All of the people in EMS complaining about not wanting to get in trouble should be using the EtCO2 (waveform capnography) and the SpO2 (pulse oximetry) to record that the patient is breathing adequately. By attaching printouts to our charts, we should be providing ourselves with great documentation of the patient’s breathing. If these are available and we don’t record EtCO2 and the SpO2, then we provide good evidence that we do not know how to manage respiratory depression. If we cannot manage respiratory depression, we should not be allowed to treat emergency patients.
 

Administration of ketamine to a patient in excited delirium allows EMS providers to rapidly perform lifesaving interventions, including vital sign assessment, cardiac monitoring, volume resuscitation, oxygen therapy, blood glucose determination, and medication administration.[1]

 

Is it acceptable to do blood glucose determination after ketamine?

Of course it is. Why use more needles than necessary when wrestling with a patient? If the patient is a known diabetic, but is combative, is it really a good idea to try to administer hyperosmolar solutions (such as D50W – 50% Dextrose in Water) through an IV to that combative patient? Not that there is any good reason for us to still be using stronger than 10% dextrose to reverse hypoglycemia.[2]

Is there a better drug than ketamine for managing the violence of excited delirium? To be continued in Part III.

Footnotes:

[1] Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium.
Burnett AM, Watters BJ, Barringer KW, Griffith KR, Frascone RJ.
Prehosp Emerg Care. 2012 Jul;16(3):412-4. Epub 2012 Jan 17.
PMID: 22250698 [PubMed - in process]

[2] 10% Dextrose vs 50% Dextrose
 

Should EMS Still Use 50% Dextrose
Rogue Medic
Tue, 03 May 2011
Article
 

Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.
Rogue Medic
Wed, 04 May 2011
Article
 

Comment on 10% Dextrose vs 50% Dextrose
Rogue Medic
Thu, 05 May 2011
Article

Burnett AM, Watters BJ, Barringer KW, Griffith KR, & Frascone RJ (2012). Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 16 (3), 412-4 PMID: 22250698

.

Laryngospasm, hypoxia, excited delirium, and ketamine – Part I

ResearchBlogging.org

One of the concerns with ketamine is the rare occurrence of laryngospasm.

Can EMS manage the airway without paralytics?

If we can find just one bad outcome,should we prohibit EMS ketamine use and thus prevent all of the good outcomes, just to be safe?

Let’s look at an actual example, rather than waxing philosophical.
 

We report what we believe is the first case of laryngospasam associated with prehospital administration of IM ketamine to a patient in excited delirium.[1]

 

Is one case in the US the tip of the iceberg, or just the rare occurrence of a rare adverse effect?

In the US, ketamine is being used in some systems, but it still appears to be uncommon. Outside of the US, ketamine is much more commonly used. Ketamine is also one of the most widely studied medications available. If this were common, or even just uncommon, rather than rare, we would have many reports of laryngospasm.

A ≈100 kg patient was given 5mg/kg (500 mg) of ketamine by IM (IntraMuscular) injection for apparent excited delirium. Within 3 minutes, he was not resisting and in a dissociated state.

This is not as fast as in the movies and wrestling with an excited delirium patient for even a few minutes can be exhausting, but this is much faster than we should expect from any other IM medication (except maybe succinylcholine).

Heart rate 101, room air oxygen saturation 98%. En route an IV (IntraVenous) line was started and oxygen by face mask was applied. Seeing a patient go from violent to sedated in a short period of time, especially with large doses of midazolam (which is known for causing respiratory depression) can make this appear to be the right thing to do, but we should be guided by our assessment.

At the ED (Emergency Department) the vital signs were – blood pressure was 137/87, heart rate 82, respirations 18, temperature 36.8°C, and oxygen saturation of 100% on 15 LPM (Liters Per Minute) oxygen by mask.
 

Approximately 5 minutes after arrival at the ED (12–15 minutes after ketamine administration), he became cyanotic. Repeat of the primary survey was notable for new upper airway obstruction, as well as absent breath sounds despite visible chest and abdominal movements that were felt to be consistent with attempted inspiration.[1]

 

What do we do?

Some paramedics will say, It’s not my patient and not my problem.

These paramedics are much more dangerous than any side effect of any drug we might give. They just don’t care. Some hospitals may have specific policies about what we may do to treat patients in the hospital, but we can always reassess the patient and point out what was similar and what was different before we got to the hospital. I have only been criticized for hooking an unstable patient up to the hospital monitor by people who think that a hospital gown is more important than the patient condition. And I ask, if there is someone in the room, before I do something. Would you like me to bag the patient? The less stable the patient becomes, the more important clear communication becomes.
 

Oxygen saturations were 20% on non-rebreather mask, with a good waveform. Head tilt/chin lift with two nasal airways was unsuccessful in clearing the obstruction.[1]

 

Would nasal trumpets (maybe expected to reach as far as the epiglottis) resolve an airway problem that is beyond the epiglottis?
 


 

That does not mean that it is wrong to attempt less invasive means of oxygenation, but that we should not be too optimistic about the outcome of these treatments. They can certainly contribute to making a diagnosis.
 

A diagnosis of laryngospasm was made, and positive-pressure ventilation with 100% oxygen via bag–valve–mask was initiated. The patient’s O2 saturations rapidly improved to 98% and breath sounds were heard bilaterally.[1]

 

Yay!
 

Assisted ventilation was discontinued and the patient was able to maintain a patent airway.[1]

 

All better!

Actually, not remotely All better! To be continued in Part II.

Footnotes:

[1] Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium.
Burnett AM, Watters BJ, Barringer KW, Griffith KR, Frascone RJ.
Prehosp Emerg Care. 2012 Jul;16(3):412-4. Epub 2012 Jan 17.
PMID: 22250698 [PubMed - in process]

Burnett AM, Watters BJ, Barringer KW, Griffith KR, & Frascone RJ (2012). Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 16 (3), 412-4 PMID: 22250698

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Excited Delirium, Sedation, and Comments – Part III

There are some more responses to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

Why do I write so much about excited delirium?

Few of our patients will have any kind of life-or-death intervention from EMS. These are some of the patients. We can make the difference between life and death.

These are also some of the least likable patients we will deal with – they are often attacking us. How do we protect ourselves and protect our patients?

Some people continue to tell us that sedation is evil.

This is from kindofafireguy

Granted, I’m no lawyer, but it seems to me the greatest potential for liability is when the standard of care is NOT met, as opposed to when it is.

So if you have protocols for chemical restraint (as my region does), to me that would imply greater liability for not restraining a patient in need of it and said patient wreaking mayhem and injuring people.

But that’s just me applying common sense. So it’s probably wrong.

I am not a lawyer, either. I think that we have too many people telling us what a jury will do, when we do not know what a jury will do. The jury determines what is the standard of care and whether that standard was met. Trying to predict what 12 people (or six) will agree on – after listening to very biased, but antagonistic descriptions of the same events and expert testimony that is similarly antagonistic – is not something intelligent people should do.

The only legal advice that makes sense to me is –

Do what is best for the patient.

The problem is that we do not always know what is best for the patient, but –

If the patient is excited, with all other patients, we would be trying to calm the patient down. With excited delirium, we seem to be going out of our way to make them even more sedated. Here are some nice soothing leather restraints.

If we follow the physical restrain promptly with chemical restraint, that is patient care.

If we do not follow the physical restraint with chemical restraint, how is that patient care?

This is from Kelly Grayson of A Day in the Life of an Ambulance Driver

“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.

There are EMS agencies near me that do not aggressively sedate agitated patients.

As our medical protocols become more and more aggressive, that is changing, but we still have to wait for some of the old medics (and old medical directors) to die off. Being treated according to their own protocols may be the best way to do that. If it does not kill them, being treated by their own protocols may convince them that their approach to patient care is not good patient care.

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.

B52 refers to a mixture of B (Benadryl – diphenhydramine) 50 mg, haloperidol (Haldol) 5 – 10 mg, and lorazepam (Ativan) 2 mg. These doses are not limits, but starting points for sedation. We can always give more, even if we have to make a phone call while in the middle of wrestling with the patient.

The Haldol does not get the recognition it deserves, but that is what is doing the most to knock the patient down – not knock the patient out. Knocking the patient down has little to do with gravity. Knocking the patient down means getting rid of the patient’s combative behavior.

The diphenhydramine is there both as a sedative and as prophylaxis against extrapyramidal symptoms.[1]

This is from an article in Emergency Medicine News on treating excited delirium –

Regardless of one’s choice of medication, the key to success is to use enough drug. Internist- and pediatrician-type doses usually don’t cut it. The PDR is clueless about effective doses for our purposes, and safety caveats in that publication are merely fodder for lawyers, not information for clinicians. The best guideline is to give enough to achieve the intended result.[2]

 

Regardless of one’s choice of medication, the key to success is to use enough drug.

 

Why do so many of us attempt to justify giving an inadequate dose?


Image source.

See also –

‘Hog-tying’ death report faults Fla. medics.

Excited Delirium, Sedation, and Comments – Part I

Excited Delirium, Sedation, and Comments – Part II

Footnotes:

[1] Extrapyramidal symptoms
Wikipedia
Article

[2] Rapid Tranquilization of Violently Agitated Patients
Roberts, James R. MD
Emergency Medicine News:
November 2007 – Volume 29 – Issue 11 – p 15-18
doi: 10.1097/01.EEM.0000298833.70829.ad
Free Full Text from Emergency Medicine News

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