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

- Rogue Medic

Capnography Use Saves Lives AND Money – Part V

Continuing from Capnography Use Saves Lives AND Money – Part I, Part II, Part III, and Part IV.
 

Another potential lawsuit involves the patient who’s been sedated or physically restrained. Restraint lawsuits are generally related to brain injury or death from “positional asphyxia,” and in the sedated patient, from hypoventilation hypoxia.

The use of continuous capnography to monitor these patients can assist your crews in reducing the chance of missed episodes of apnea or respiratory distress due to patient positioning of restraints. EMS providers alerted to the fact that a patient is hypoventilating could enable them to adjust restraints, reposition the patient or reduce or stop sedation long before significant hypoxia occurs.[1]

 

Unlike the medical directors, who ignore the risks of physical restraint, Patricia Brandt shows how these risks may be mitigated with waveform capnography. Perhaps data from these patients would demonstrate just how aberrant the vital signs of these patients can be.

We sedate a patient and decrease respirations from 40 to 20 and the respiratory depression is terrifying. How will EMS possibly deal with a sedated patient with a normal respiratory rate? The horror. The horror.

Or, we do not provide any treatment and wash our hands of this tachypneic, tachycardic, hypertensive patient. We are EMS. Nobody should expect us to actually provide treatment to minimize the risks of these conditions, because this patient doesn’t fall into the right protocol.

If a tachycardic patient dies, while we ignore his medical condition, nobody should blame us or blame the medical director who writes protocols to specifically exclude these patients.

If a respiratory distress tachypneic patient dies, while we ignore his medical condition, nobody should blame us or blame the medical director who writes protocols to specifically exclude these patients.

If a hypertensive patient dies, while we ignore his medical condition, nobody should blame us or blame the medical director who writes protocols to specifically exclude these patients.

If a disoriented patient dies, while we ignore his medical condition, nobody should blame us or blame the medical director who writes protocols to specifically exclude these patients.

We will just claim that the treatment that would have sedated the patient and prevented the death is too dangerous.

Ignorance is our defense.
 

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.[2]

 

The highlighting is mine.

The pathogenesis of excited delirium deaths is likely multifactorial and includes positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal arrhythmias.

These should be avoidable with appropriate sedation, which is much safer when accompanied by waveform capnography.

Treatment should focus on prevention through the reduction of stress.

This is simple enough that even a jury should understand it.
 

Excited delirium information –

Excited Delirium: Episode 72 EMS EduCast

Excited Delirium: Episode 72 EMS EduCast This is my post about the excellent EMS EduCast coverage linked just above.

Excited Delirium 2.

Agitated Delirium Comment from RevMedic

A Naked Woman – TOTWTYTR – Part I

Not Sedated – Restrained

An excellent source of information about waveform capnography can be found at Capnography for Paramedics.

Footnotes:

[1] Capnography Use Saves Lives & Money
By Patricia A. Brandt, RN, BSN, MHR
JEMS.com
Article

[2] 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]

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Comments

  1. Why is it that we as a society feel that sedation is a perfectly acceptable (if not the most humane) method of dealing with large and/or dangerous animals, yet people in the same agitated/stimulated/hyperactive/overstimulated state are just acting out and can be cured by handcuffs along with being piled upon by every cop, FF, and medic in the vicinity?

    Just a casual observation.

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