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

- Rogue Medic

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

.

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

.

Excited Delirium, Sedation, and Comments – Part II

-

Others responded to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

CombatDoc wrote –

Why are medics so scared of sedation?

This is the main problem.

Ignorance leads to fear.

But this does not lead to Yoda quotes.

We should not be arrogant, assuming that we know everything about the drugs we use. That can be just as dangerous as ignorance, but we need to learn more about the medications we use.

Too many people tell us that sedatives and opioids are dangerous. These are probably the safest drugs we use. They have well known side effects, but the side effects are not remotely as common as the Just say No people would have us believe.

We need to base our treatments on understanding, not fear.

If we understand what we are doing, we will continually reassess our patients, but we should do this with every treatment, not just the treatments portrayed as evil.

-

My favorite comment in a chart of a patient that I suspect of ED is, “Pt arouses to voice and is resting comfortably on the cot.” That is a properly treated patient.

Exactly.

The purpose of sedation is to sedate.

That is a description of a sedated patient. We are not supposed to be producing awake and alert and cooperative patients. That is asking the impossible.

We are supposed to be sedating the patient to the point of both no longer being a danger to himself and no longer being a danger to others. Awake and alert have nothing to do with that.

-

I have had very good results with initial doses of 5mg IN or IV of Versed and 10mg IM Versed. I always followed up the IN/IV with an IM dose since studies, cannot find the original one, have shown IM as a better route with less resedation needed.

I would prefer to use IV (IntraVenous) midazolam over IM (IntraMuscular), because it wears off pretty quickly when given IV, especially with the exaggerated metabolism of excited delirium patients. The reality of excited delirium is that an IV is usually not practical, so I have to settle for longer duration and less predictable absorption.

I like the idea of the sedative wearing off quickly, because some patients just need to have their excited delirium interrupted. After a period of sedation, some are able to be reasoned with. Some will ask for more sedation, because they realize they cannot control they way their body is acting. This can be like a panic attack. The patient would like to control it, but does not do well without sedation. It should not be a surprise that benzodiazepines are commonly used for panic attack.

How have your results been with IN (IntraNasal) midazolam for excited delirium?

-

-

I know there are risks and apnea is one. Not a fan of doing that on purpose but, we can all handle that.

If a medic cannot handle respiratory depression, or apnea, by BLS (Basic Life Support) methods, should that person be allowed to use any ALS (Advanced Life Support) treatments?

We can’t handle simple cases of respiratory depression, but we should still be allowed to play paramedic?

No.

Absolutely not.

-

I am seeing more and more of these patients and more and more are ending up chemically paralysed on ventilators until the Spice or Bath Salts are out of their system.

I was wrong about bath salts. I did not think this would become a big deal. Maybe I am just getting old and do not understand how stupid people will be to get a high. Maybe I need to chase some kids off of somebody’s lawn, somewhere. :oops:

I guess the doctors just don’t have enough faith in the power of leather restraints./

-

Maybe someday my medical director will give us Ketamine….

That would be great.

Sedation has so many uses, that we our patients are really missing out on an excellent treatment for a variety of conditions.

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Shane, so you have a stance that the hyperthermia, lactic/metabolic acidosis, rhabdo, dehydration, extreme hypertension, etc. that leads to renal failure, MODS, cardiac dysrhythmias, stroke and sudden death is not something that needs to be worried about? Last I checked most of those can kill pretty quickly. All those are a direct result of the patient that is out of control and fighting and struggling. My guess is you have never walked in the house to see every piece of furniture, every appliance, bathroom fixtures, windows, etc. all destroyed by a 150lb guy standing there naked and ready to fight. Not a fun call and a VERY dangerous situation for all involved.

The people who deny excited delirium exists are not the people who work in EMS, emergency medicine, or the police.

The people who deny excited delirium exists are the people who deal with patients who have already been sedated by EMS and the ED (Emergency Department).

If we do not sedate these patients, we may miss the last opportunity to save their lives.

All for a lack of understanding of sedation.

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Excited Delirium, Sedation, and Comments – Part I

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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.

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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.

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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.

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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?

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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.

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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 . . . ?

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

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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.

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

Clearly.

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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

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