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

- Rogue Medic

On Human Bondage and the Art of the Chemical Takedown

For a great podcast on excited delirium listen to the EMCrit podcast on this topic.[1] And read the comments.

Some of Dr. Weingart’s points –

This is not the management of the already medicated patient. At least these patients are generally not taking psychiatric medications.

Martial arts joint locks do not work. He also says that using the patient’s weight against him/her does not work. I think he means throws and other similar moves. Leverage is extremely important for controlling the patient and the patient’s extremities. Using the patient’s weight and momentum against the patient for the purpose of getting a limb into a position where the patient has as little ability to move as possible is part of the goal.

I like to control the head. As Dr. Weingart points out, bites are a problem. I disagree about gloves. They will not offer much protection. Do not expect thick gloves to prevent the patient from biting off a finger, or crushing a finger. The palm of the hand should go against the side of the zygomatic bone (cheek bone) pushing down with the palm of my hand, but curling my fingers back. Do not let up pressure. The best way to control the body is to control the head. If I let up, I make it much more likely that someone will get hurt.

Dr. Weingart likes to just get into a large muscle quickly inject a droperidol and midazolam mixture (probably more than you are comfortable with, but how comfortable are you with wrestling?), and quickly remove the needle and get out of the way. Here is the kind of approach I expect from Dr. Weingart.


Picture credit. Here’s droperidol!

Two important warnings.

1. Do not hog tie patients. This video should make it clear how quickly things can go bad when we hog tie people.

[youtube]GdzpoS8pTks[/youtube]

2. Do not give oxygen. This is a topic for a whole series of posts, but listen to him. These patients are hyperventilating, so they should be oxygenating well. Rather than oxygen, use waveform capnography to assess the quality of ventilation.

And read the comments. There is a great dialogue among the doctors there.

One important part of one comment is this from Dr. Minh Le Cong –

Common mistakes are usually underdosing the patient with an ineffective agent and this risks subsequent overdosing the patient with repeated doses.

This is the biggest problem I see with EMS sedation of excited delirium – not enough of the wrong drugs. Even if we give enough, without ketamine or droperidol, we are using the wrong drugs. The extreme of this is to not have any standing orders for sedation of excited delirium – how much more not enough of the wrong drug can we get than when we Just say No.

Go listen to the podcast and read the comments.

See also –

Excited Delirium: Episode 72 EMS EduCast

Capnography Use Saves Lives AND Money – Part V

Droperidol, QT prolongation, and sudden death – what is the evidence – Part I

Or just click on the Excited Delirium category.

Footnotes:

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

.

Comments

  1. In the area that I practice paramedicine we have a protocol, not specifically for excited delirium, but for a combative patient. Prior to medical control contact we may give 2.5 up to 5 of midazolam IM for the combative patient. I would classify excited delirium in that Dx and I have given it to patients for this several times. If this doesn’t work we can always call for more of the midazolam or some diazepam. I definitely do not practice in one of the ” mother may I ” jurisdictions that I have heard about, thankfully. Once we have the patient chemically sedated we have leather restraints in case the sedative wears off but our transport times are generally only 10-15 minutes, max. It’s unfortunate that so many of my peers in this nation must needlessly risk their lives and their patients lives everyday for this easily managed patient.

    • David,

      In the area that I practice paramedicine we have a protocol, not specifically for excited delirium, but for a combative patient. Prior to medical control contact we may give 2.5 up to 5 of midazolam IM for the combative patient. I would classify excited delirium in that Dx and I have given it to patients for this several times. If this doesn’t work we can always call for more of the midazolam or some diazepam.

      My experience has been that 5 mg IM midazolam will not do much, even for small patients. If you read the comments at EMCrit, they are mostly divided between droperidol and ketamine as the best sedative, with just a little a bit of midazolam (5 mg is a little bit for these patients) to take the edge off.

      I definitely do not practice in one of the ” mother may I ” jurisdictions that I have heard about, thankfully. Once we have the patient chemically sedated we have leather restraints in case the sedative wears off but our transport times are generally only 10-15 minutes, max.

      You are calling for command beyond a tiny dose of midazolam, so you do not completely escape the Mother-May-I medical command syndrome that causes so many doctors to ignore reality at the expense of patients. How many people do you have responding to one of these patients, that you can give them the first dose and wait for the medical command doctor to admit that the still combative patient is not responding to the small dose of a drug that is not predictably absorbed when given IM?

      A 10 – 15 minute trip could have the midazolam wearing off as you are arriving at the hospital. The metabolism of these patients is much higher than normal.

      It’s unfortunate that so many of my peers in this nation must needlessly risk their lives and their patients lives everyday for this easily managed patient.

      The patients should not be seen as easily managed. We need to be constantly assessing them, because they are at risk of sudden death.

      Any requirements for medical command permission while dealing with a combative patient are dangerous to patients, EMS, police, fire, security, techs,nurses, doctors, bystanders, and the other patients in the hospital.

      .

  2. Walked into the county jail clinic many years ago. I forget what the nature of call was for, but when we finally arrived, the patient was in an ExD state. Of course back then I didn’t know what ExD was or that it even existed. I contacted medical control, described what was going on. The doc asked me what I had for sedation, which at the time, the best I had was 40mg diazepam. He directed me to start with 20mg, but use the lot of it if I needed to. So the patient got 40mg diazepam IM (all we had on the rig), 20 at a time in each butt cheek while he was dancing with several of the guards. It seemed to work in roughly 10 minutes, after which dude was not fighting and willing to walk anywhere. He was still a bit on edge, but at least cooperative and manageable.

    Nowadays, I have much larger arsenal besides the diazepam; Haldol, thorazine, and versed, but more importantly I have the knowledge that this is real and the experience to not be afraid of treating/dealing with it appropriately.

    • Dewayne,

      Walked into the county jail clinic many years ago.

      That is always a good way to start a story, unless in a job interview or meeting the parents of someone you want to marry.

      I forget what the nature of call was for, but when we finally arrived, the patient was in an ExD state. Of course back then I didn’t know what ExD was or that it even existed. I contacted medical control, described what was going on.

      The rolling of the dice and hoping that the doctor answering the phone does not think that all EMS is good for is transport.

      The doc asked me what I had for sedation, which at the time, the best I had was 40mg diazepam. He directed me to start with 20mg, but use the lot of it if I needed to.

      Yay! I am always happy to be wrong when I am pessimistic about medical command.

      So the patient got 40mg diazepam IM (all we had on the rig), 20 at a time in each butt cheek while he was dancing with several of the guards. It seemed to work in roughly 10 minutes, after which dude was not fighting and willing to walk anywhere. He was still a bit on edge, but at least cooperative and manageable.

      Diazepam can be a great drug IV (when a long lasting drug is desired), but IM (IntraMuscular) is also an acceptable route.

      DOSAGE AND ADMINISTRATION
      Dosage should be individualized for maximum beneficial effect. The usual recommended dose in older children and adults ranges from 2 mg to 20 mg IM or IV, depending on the indication and its severity. In some conditions, e.g., tetanus, larger doses may be required.

      DIAZEPAM injection, solution
      [Hospira, Inc.]

      DailyMed
      FDA Label

      Cooperative and manageable is the goal. This is something that the doctors discuss in the EMCrit comments particularly this one from Dr. Minh Le Cong.

      Nowadays, I have much larger arsenal besides the diazepam; Haldol, thorazine, and versed, but more importantly I have the knowledge that this is real and the experience to not be afraid of treating/dealing with it appropriately.

      That is important. As Dr. Minh writes elsewhere –

      Common mistakes are usually underdosing the patient with an ineffective agent and this risks subsequent overdosing the patient with repeated doses.

      We are too often too hesitant to interrupt the escalating metabolic stress, both with excited delirium and with CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). We wait too long and we end up intubating and attempting to resuscitate these patients.

      I would prefer droperidol and midazilam or ketamine and midazolam (ketamine and succinylcholine is another possibility).

      Great job.

      .

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