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

- Rogue Medic

What Do I Want to See Under My Tree from EMS Santa


Image credit.

There is one change to my protocols that probably would not be used often, but when used would more than make up for the lack of use.

What would a rogue want? It isn’t an EMS helicopter.

I have written about so many things that are really nice treatments.

High-dose IV (IntraVenous) NTG (NiTroGlycerin or GTN – GlycerylTriNitrate in Commonwealth countries)?

I am fortunate to have state protocols that include this, although not where I work. I can give multi-dose SL (SubLingual) NTG where I work. I can do enough with that and the short transport times, that this is not at the top of my list.

Remove furosemide (Lasix) from the paramedic scope of practice?

It has been moved to requiring medical command permission. This is one case of the Just-Say-No aspect of on line medical command that is not horrible. Still, the better thing to do is to just trash the furosemide. Maybe with the next protocol revision it will be as the medical directors realize that it is not a good drug.

Full standing orders for everything I have with no need to call for any dose, no matter how high, or for any mixture of opioids and sedatives at any dose?

Again, that would be nice, but it is not at the top of my list, because I already have pretty liberal standing orders and the medical command doctors have not refused any dose for me in years. Part of that is just knowing the doctors, but this would be a really good present for a lot of the medics who are new, or are new to an EMS service.

The standing orders are for musculoskeletal pain, no longer just for isolated extremity trauma (and burns and chest pain).

Droperidol (Inapsine)?

I have written a lot about droperidol, and I will write a lot more, but I think that this is something that needs to develop a comfort level among the ED (Emergency Department) physicians before they will be comfortable allowing EMS to use droperidol. Once the doctors realize how useful it is, again (or for the first time, for the newer doctors), then it should be quickly made available to EMS.

RSI (Rapid Sequence Induction/Intubation)?

We have etomidate (Amidate) available for services that will have at least 2 paramedics on scene, but this is not RSI. The state calls it DFI (Drug Facilitated Intubation). The dose is 0.3 mg/kg with a maximum of 30 mg. Why? Obviously, patients weighing more than 100 kg are too easy to intubate, so we will use lower per/kg doses for them. 😳

DFI? No this is CFI – Charlie Foxtrot Intubation. It is unreasonable for me to expect anything to change with this until medical oversight becomes better. When paramedics develop some real skill at intubation, then RSI may become available to EMS in Pennsylvania.

As much as I don’t like the choice of medication, or the dosing, the biggest problem is the competence of the medics attempting intubation – averaging one per year and not practicing in between.

What about real medical oversight?

Yes. That would be a great present – for medical directors in the area to understand how to provide oversight and to be aggressive in encouraging EMS to be better. There is already some of that, but there are other medical directors who have a long way to go. I was tempted to make this my choice, but I want to be more realistic.

Realistic in EMS? In a post about Santa?

Just more realistic. Besides, as I have already pointed out, I have a lot of what I would want, now. I am very pleased with the progress made in Pennsylvania. When I was on our county protocol committee, we had none of the things I mentioned that we have now.

So what do I want?

I’ll tell you after I open my presents tomorrow.

.

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

.

What is Excited Delirium

In the comments to What is a Long QT Segment and How Does Droperidol Affect It is this from Dewayne –

My experience with excited delirium (I just can’t bring myself to type ED without laughing) is that it occurs more than we acknowledge.

This appears to be the essence of the disagreement on this topic.

The reason we do not acknowledge or recognize it, is that we are not taught about it. Again this is from my experience in my area.

I agree.

This is the patient who cannot be talked into cooperating.

The cooperative patient wants to feel less stressed and will allow treatment with some sort of sedative.

As firetender suggested, there is the possibility of talking these patients down, but they should be sedated. As much as these patients may seem to be cooperating, they can suddenly become excited again.

This is not being unfair to the patient. If the previously cooperative unrestrained patient suddenly decides to leave the ambulance while the ambulance is moving, the result can be a severely injured patient, a dead patient, a severely injured medic, a dead medic, a crashed ambulance, a multi-vehicle crash, or some combination of these.

These patients need to be sedated to decrease the metabolic stimulus and to allow the patient to come down from whatever is causing this stimulus, whether psychological, chemical, or both.

Looking back over the years, I can remember several cases that were more than likely excited delirium, but at the time it was chalked up to behavioral outburst, drug or alcohol ingestion, or just plain crazy.

There are several emergencies that require a rapid focused assessment and a quick decision. Can’t intubate/can’t ventilate, anaphylaxis, tension pneumothorax, excited delirium, et cetera

Quite honestly it’s a small miracle that we didn’t kill any of these patients. Well patients is a bit of a misnomer as most were carted off by the police, which makes even more of a miracle that some of them didn’t die.

More early sedation (chemical restraint) should mean less physical restraint.

Physical restraint does increase the metabolism.

The problems are that –

We do not have a sedation gun.

We do not have a practical alternative to restraint.

We have patients who are unpredictable.

Delirium is sudden severe confusion and rapid changes in brain function that occur with physical or mental illness.[1]

Physical illness and/or mental illness and/or drugs (including alcohol).

Delirium does not produce predictable or consistent behavior.

When the excited part of excited delirium is added, things become dangerous.

Inability to think or behave with purpose[1]

Speech that doesn’t make sense (incoherent)[1]

Inability to stop speech patterns or behaviors[1]


Click on the image to make it larger.

Is it responsible behavior to not restrain these patients?

The real questions are –

What is the best way to administer chemical restraint?

What are the best chemical restraints?

When we try to explain the behavior of patients with delirium, we assume that their behavior is rational. To assume this is irrational.

[youtube]ZF2yPLkElfE[/youtube]

I guess what I’m getting at is that we have to improve our educational standards. This is the key to us moving forward and improving patient care.

Amen!

It’s unfortunate that there are greater exchanges of ideas, information, and intellectual debate in the various blogs than is taking place in the EMS class rooms.

Depends on the classroom.

Blogs are becoming an important source for sharing information about improving patient care.

Classrooms are also improving.

Footnotes:

[1] Delirium
PubMed Health
Article

.

A Killer Diagnosis?


Expletive deleted Horror Shows! is firetender’s response to my Thanksgiving Day post Happy Excited Delirium.

Again, firetender is claiming that the officer is making a diagnosis. He is demonstrating this by using non-medical definitions of diagnosis and assessment. Is this any different from the creationists who pretend that a scientific theory is the same as an opinion.

We should not expect a fundamentalist to understand science. Likewise, we should not use a non-medical definition for medical terms.

At 23:48., the room is silent, the cop is on the phone and making the diagnosis.
(Let me say that again: Making a diagnosis!)

That is not a diagnosis. Here is what I wrote –

At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case.
This is excellent communication and the right assessment.

This is not a diagnosis.


Image credit.

So, technically, no, that was not an assessment. The Officer specifically used medical terminology to describe a medical condition

What if the police officer says –

I believe we have a diabetic emergency.

I believe we have a GSW (Gun Shot Wound).

I believe we have a cardiac arrest and I am initiating compressions and attaching the AED (Automated External Defibrillator.

Are these diagnoses? They all use medical terminology, but that does not make them diagnoses. Imagine if he had used the word that every EMT learns to use, rather than sweaty – diaphoresis? Would that be a diagnosis?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; restraint and sedation.

If the police mention diabetic emergency on the radio, am I required to initiate treatment under the hypoglycemia portion of an altered mental status protocol?

If the police mention GSW on the radio, am I required to initiate treatment for a GSW under a trauma protocol?

If the police mention cardiac arrest on the radio, am I required to initiate treatment under a cardiac arrest protocol?

What if none of these assessments are accurate?

What if the diabetic patient is not really diabetic, or has a different cause of altered mental status, or does not even have altered mental status?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; dextrose.

What if the GSW patient has not been shot, or the wound is minor, or something else?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; 2 large bore IVs, non-rebreather mask/intubation, rapid transport to a trauma center.

What if the cardiac arrest patient never had a cardiac arrest?

Once that call was made, a course of treatment was embarked on based on the protocols surrounding the intervention in such medical conditions; CPR, intubation, epinephrine, defibrillation, therapeutic hypothermia, et cetera.

In other words, NO. The police do not determine EMS treatment.

Does EMS call the police for treatment orders?

No.

If the mention of excited delirium syndrome by a police officer caused some requirement for sedation, where was the sedation?

It is impossible at present to know how many patients receive a therapeutic intervention that stops the terminal progression of this syndrome.

One reason for that is, as the first article described, the diagnosis is most often applied to a dead person after the fact of forcible restraint by LEOs.

No, but feel free to try to come up with some evidence of this.

I don’t know how more clear this White Paper can get; The diagnosis of Excited Delirium is NOT derived from Evidence-Based Medicine. In that respect, I’d imagine Rogue would have to agree with me; DO NOT ACCEPT ExDS AS A VALID DIAGNOSIS!

The authors of the paper make it clear that they are basing this on the best available evidence. Writing in ALL CAPS does not change that.

There is no current gold standard test for the diagnosis of ExDS.
… combination of delirium, psychomotor agitation, and physiologic excitation differentiates ExDS from other processes that induce delirium only.
…Similarly, subjects who are agitated or violent but who do not also demonstrate features of delirium simply do not meet the definition of ExDS.

What is a syndrome?

Syndrome: A set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease.

What was the title of the white paper?

White Paper Report on Excited Delirium Syndrome.

Do you assume that the definition of syndrome is something that is irrelevant, or do you just not know that it is relevant, or do you just not know what a syndrome is?

Basically, they’re saying that there doesn’t appear to be a “cause and effect” between use of restraint or chemical/electrical controls and death. But, really, how can they say that when the only cases of death through so-called ExDS are precisely on the heels of the application of force?

When people are killed by the application of force, there are usually some signs of the cause of death. Cause and effect. Excited delirium syndrome is different. There is no injury that explains the death. Fighting with police is not necessary, but extreme physical exertion does appear to be necessary.

If you figure out how to sedate people without the exertion, that would be great.

Getting excited delirium syndrome patients to voluntarily stay in a calm comfortable room is great – right up until the patient decides to leave and go play in traffic, and kick little old ladies over and over, and throw children around, and whatever else?

Until there is a safe, dependable, fast acting remote tranquilizer available, force is going to be a part of the solution.

Sedative or dissociative agents such as benzodiazepines, major tranquilizers, and ketamine are suggested but there is no evidence yet to prove that these will result in a lower morbidity or mortality.

There does not appear to be any research to demonstrate clearly that sedation saves lives, but we do know that continuing extreme exertion by these patients frequently results in death. What is frequently? That is difficult to answer. They do estimate that the dramatic decrease in estimates of the death rate is due to psychiatric medication.

What would be the treatment for a patient in an ICU with similar extremes of metabolism?

Sedation?

White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated to add link to the White Paper being discussed on 7/23/2018. This should have been included originally.

More Happy Excited Delirium Commentary

First, CCC (Captain Chair Confessions) is looking for protocols. Go give him a link to your protocols. This looks as if it will be a very useful way for us to show their medical directors how things can be better.

Fishing for protocols.

CCC responded to the videos in Happy Excited Delirium Commentary with –

That dude was tripping hard.

A little too hard.


Image credit.

If that’s a bad trip, I wonder how good the good trip would be?

How good depends on your preferences. Just as with a preference for beer, or wine, or liquor, or cigarettes, or marijuana, or anything else – tastes vary. However, there does not appear to be any valid excuse for reality TV. 😉


Image credit.

This doesn’t look like a good trip to me, but not everyone has the same idea of a good time. Maybe this is what he thought he was looking for, but when his mind got there, he didn’t like it.

All I carry to sedate is 4mg Versed and 20mg Valium. I don’t think that would be enough for homeboy.

For the first patient, that amount of midazolam (Versed) and diazepam (Valium) should be enough. He was cooperating as much as he could, but for the second patient (who may also have been cooperating as much as he could) more would probably have been needed. If for no other reason that the patient appears to weigh a lot more. Drugs are supposed to be give according to body weight.

Remember that (with medical command permission) you can also use opioids to sedate, so morphine and fentanyl can be given in addition to the tiny amount of benzodiazepines that you carry. Diphenhydramine (Benadryl) is another drug that can be used to sedate. One of the benefits of diphenhydramine is that it will counter the extrapyramidal symptoms that are often produced by haloperidol (Haldol) if any haloperidol is on board or any of the other drugs that may cause extrapyramidal symptoms (haloperidol is just the drug that most commonly blamed for this).

I know what some people are thinking – How can 4 mg midazolam and 20 mg diazepam be a tiny dose?

I am not a mind reader, but I do receive this kind of response to so many things that I do, that I am not surprised when some medically naive people state something similar to this.

Allow me to provide an example –

I was treating a teenager who was less than 50 kg. This patient was very agitated/excited and her inability to put two syllables together in a coherent way strongly suggested delirium. After 10 mg midazolam, she was still very tachycardic and tachypneic, but there was no change in her coherence. Blood sugar was normal.

This may be a little less than 4mg Versed and 20mg Valium, but not much.

She was a small patient. 50 kg is 110 pounds and she weighed less than that.

After the midazolam doses (5 mg and 5 mg), she was maintaining a sat of 100% on room air. Her respiratory rate was still twice what it should have been, even though she had respiratory depression compared with her initial respiratory rate. With respiratory depression, she was still breathing too fast.

She was breathing too fast and the patient had respiratory depression compared to what her initial respiratory rate was.

Maybe she needed more sedation.

.

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


ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

I am continuing to look for evidence that droperidol deserves to be given a scarlet letter black box warning. The authors of this literature review take a look at several articles and some case studies.

Because the outcome of interest, sudden death caused by torsades de pointes, is uncommon and difficult to assess, QT prolongation has become a surrogate marker for potential arrhythmogenicity and is therefore commonly used in research and by regulatory agencies.18[1]

Surrogate endpoints are great for making it seem that we know more than we actually do know. When there is not enough information, surrogate end points are a way of saying, If this belief is true, and this other belief is also true, then Treatment Z is safe (or dangerous), or saves X number of lives per year (or kills X number of patients who otherwise would have been expected to live).

The example that I repeatedly use is the Cardiac Arrhythmia Suppression Trial,[2] which ended up demonstrating that treatment based on the surrogate endpoint of eliminating PVCs (Premature Ventricular Contractions) because they are associated with a higher rate of death actually resulted in tens of thousands of extra deaths.[3] That is the difference between looking at surrogate endpoints (making assumptions about death rates) and looking at actual death rates.

a consistent relationship between the length of the QT interval and the risk of torsades de pointes or sudden death is not clearly established and might vary from drug to drug and from individual to individual. Hundreds of drugs are known to prolong the QT interval, with widely variable degrees of evidence for clinical dysrhythmias.16,17 [1]

What did the authors find?

Because of the small number of studies and articles identified, we were unable to perform a true systematic review (ie, meta-analysis)22 [1]

First, what does the FDA (Food and Drug Administration) label recommend as the dosage of droperidol?

Adult Dosage: The maximum recommended initial dose of droperidol is 2.5 mg I.M. or slow I.V. Additional 1.25 mg doses of droperidol may be administered to achieve the desired effect. However, additional doses should be administered with caution, and only if the potential benefit outweighs the potential risk.[4]

As if that caution does not apply to the use of every medication.

In one surgical study of 40 patients receiving three weight-based doses of droperidaol, which if given to a 70 kg adult, would be doses of 7 mg, 12.25 mg, and 17.5 mg. Much higher than 2.5 mg. Yes, this is surgery, so what does the FDA recommend about surgical dosing?

Dosage should be individualized. Some of the factors to be considered in determining dose are age, body weight, physical status, underlying pathological condition, use of other drugs, the type of anesthesia to be used, and the surgical procedure involved.[4]

They certainly were not excluding surgery from their dosing recommendation.

QTc interval prolongation occurred within 1 minute of injection and did not increase with time. Prolongation of the median QTc interval occurred by 37, 44, and 59 ms, respectively, in a dose-dependent fashion; this was also statistically significant (P<.003). [1]

Of these patients receiving very high doses, how many died?

No dysrhythmias developed. [1]

There was a lower dose surgical study and a long-term psychiatric study. Again, there was QT prolongation, but no arrhythmia (dysrhythmia and arrhythmia are synonyms).

And there is one ED (Emergency Department) retrospective study –

Over a 4-year period, 15,374 patients received 18,020 doses of droperidol. Of the 682 patients who had an ECG performed after droperidol administration, 14 (3.1%) had prolonged QT intervals (defined as >480 ms) without evidence of any bundle branch block. Four of the 14 patients had previously documented prolonged QT intervals not associated with droperidol use. A control group (n=100) who had ECGs performed without the administration of droperidol had a similar incidence of prolonged QT intervals (4.0%). [1]

The patients who received droperidol appear to have been less likely to develop QT segment prolongation. With droperidol – 3.1% had QT prolongation. Without droperidol – 4.0% had QT prolongation.

The control group only had 100 patients, so each patient represents 1.0%, but if droperidol is so dangerous there should be more QT prolongation in the droperidol group. Maybe there is something about the way that droperidol is used in the ED that decreases the supposed danger.

These studies do not mean that droperidol is safe, but they do raise questions about the rush to add a black box warning to the droperidol label.

With the black box warning, the FDA essentially says, Lawyers, look here. You don’t have to demonstrate that droperidol is dangerous – we did that for you. Go sue some doctors.

These studies do not support the claim by the FDA that droperidol is dangerous. In Part II, I will continue with the case studies reviewed by the authors.

Footnotes:

[1] Droperidol, QT prolongation, and sudden death: what is the evidence?
Kao LW, Kirk MA, Evers SJ, Rosenfeld SH.
Ann Emerg Med. 2003 Apr;41(4):546-58. Review.
PMID: 12658255 [PubMed – indexed for MEDLINE]

[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101 [PubMed – indexed for MEDLINE]

Free Full Text Article from N Engl J Med with links to Free Full Text PDF download

CONCLUSIONS. There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide. Nonlethal events, however, were equally distributed between the active-drug and placebo groups. The mechanisms underlying the excess mortality during treatment with encainide or flecainide remain unknown.

[3] C A S T and Narrative Fallacy
Rogue Medic
Article

[4] DROPERIDOL injection, solution
[Hospira, Inc.]

FDA label
DailyMed
Dosage and administration

Kao LW, Kirk MA, Evers SJ, & Rosenfeld SH (2003). Droperidol, QT prolongation, and sudden death: what is the evidence? Annals of emergency medicine, 41 (4), 546-58 PMID: 12658255

.

Happy Excited Delirium Commentary


Expletive deleted Horror Shows! is firetender’s response to my Thanksgiving Day post Happy Excited Delirium.

At 23:48., the room is silent, the cop is on the phone and making the diagnosis.
(Let me say that again: Making a diagnosis!)

Is he making a diagnosis?

No.

That is not a diagnosis. Here is what I wrote –

At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case.
This is excellent communication and the right assessment.

I did not call it a diagnosis.

The police officer did not call it a diagnosis.

It was a heads up notification and it was the correct assessment of the condition of the patient.

I would be extremely hesitant to diagnose someone as Excited Delirium when it is not a persistent state wrapped around tension.

This is a big part of the problem. The agitation keeps coming back.

It only takes an innocent comment to set him off and he is screaming, Mom! They’re trying to kill me.

Nobody was trying to kill him.

How do we talk down excited people, when their altered perceptions affect how they interpret what we tell them?

How do we protect these patients (yes, patients), when they may suddenly decide to run from the quiet, calm room we want to use to talk them down?

I would be extremely hesitant to diagnose someone as Excited Delirium when it is not a persistent state wrapped around tension.

If a patient keeps having runs of VT (Ventricular Tachycardia), but they go away, then return, then go away, then return, do we try to talk them down? It could be that agitation (stress) is the culprit.

If the patient is having seizures, but the patient stops seizing, then has another seizure, then that stops, then there is another seizure – do we try to talk the patient down? Clearly, this is just the brain exhibiting over-stimulus.

Sometimes taking the time to do nothing is the best thing you can do to “do no further harm” and adequately TREAT an emergency.

On that we agree. Except, I do not think that this patient was appropriate place for that kind of intervention (no intervention).

Yes, if he has arranged with you ahead of time to keep an eye on him while he is tripping – then this is the appropriate thing to do. That is not the case with 911 patients.

I’ll say it again, this was a trip gone worse because of forcible intervention.

Maybe.

Maybe not.

We can only speculate at how things might have turned out differently if they had just tried to talk him down.

We can also speculate on how things would have been handled differently if he had been sedated early.

This is much more than someone who has just lost his cool.

[youtube]BkYBJId7WZs[/youtube]

Assuming that you are the person who has been asked to keep an eye on some people who are tripping for the first time and do not know how they will respond to the perceptual changes of hallucinogens, would the trippers really object to having some sedatives available to mellow out their bad trip, if it does end up being a bad trip?

Let me put this a different way?

Assuming that you are the person who has been asked to keep an eye on some people who are trying heroin for the first time and do not know what the right dose of street heroin is, would the heroin users really object to having some naloxone available to deal with excessive respiratory depression, if it does end up being an overdose?

Is it in any way unethical to deal with an adverse response to a drug, by giving a different drug to decrease the negative effects of the original drug?

How do we know that the patient will not continue to get more agitated?

We don’t know.

Just because he is able to remain calm and lie down for a while does not mean that he will continue to cooperate.

Oh, no! Now where is he going?


Image credit.

What happens if the patient bolts from the quiet room and goes dashing in and out of traffic?

Wouldn’t he be better off if he were sedated?

.

Happy Excited Delirium


What a Trip! is a post over at EMS Outside Agitator. firetender discusses a video of Excited Delirium Syndrome (ExDS). Some people may think that this patient does not have excited delirium, because the patient is so cooperative. That is a mistake.

If EMS had this patient on the monitor, there would be a lot of artifact, but we should expect to see a very elevated heart rate. Probably over 120 beats per minute. The patient is not trying to harm anyone else, but his body is working so hard that he can be hurting himself. He is a danger to himself. If over 8% (one out of every dozen) of these patients die from excited delirium, he will probably not die.

Wait – looking at those numbers is misleading without putting the numbers in context.

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]

We also do not know how much sedation will affect the outcome. We need some sort of studies comparing the outcomes of excited delirium patients who are not sedated with the outcomes of excited delirium patients who are sedated.

While regular exercise is protective and youthful bodies can withstand more punishment, extreme stress can kill, and stress is most extreme near the end of a race.[2]

When the person is restrained, there is no end of the race. It is just fight against the restraints until there is no fight left.

The patient is vigorously struggling against the straps, even though he did cooperate and lie down when the officer asked him to. Just because he is not trying to hurt anyone does not mean that he is not struggling. This is a form of extreme exertion.

If you want to know what this is like, have someone strap you to a board. Then have them inject you with a large dose of epinephrine. Then you can try to get out by breaking the straps. Maybe you will not try very hard, but if you do put a lot of effort into this, you will quickly exhaust yourself. Maybe you will kill yourself. This is extreme exertion and the people involved are usually not in excellent physical shape.

I am just kidding about the epinephrine. While it would be one way to experience what the patients are experiencing, it is a really bad idea. Epinephrine might as well be a heart attack in a syringe.

Maybe this is the rhythm –

Maybe this is the rhythm –

Maybe it is some other rhythm.

We don’t know.

We can’t tell.

firetender has a video on his post, but there is a better video here. Unfortunately, I cannot embed it. This starts with the call to dispatch, then switches to video from the scene.

At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case. This is excellent communication and the right assessment.

What should EMS do for excited delirium?

Sedation.

What if that doesn’t work?

More sedation.

What if that doesn’t work?

Even more sedation until it does work or we run out of sedation.

At 5:37 (of the linked video) someone mentions, We’ve got Narcan and Haldol, or he said We gave Narcan and Haldol. I did not hear any other mention of EMS medications at any point, but the narrators drown out a lot of what is said.

Naloxone (Narcan) will only make this patient worse. If I run out of sedative, I want to give him morphine or fentanyl until he is sedated or until I run out of sedating medication to give. Opioids do have a sedating effect. Naloxone is for respiratory depression – where is there any sign of respiratory depression?[3] If we give naloxone to these patients, we may kill them.

Was naloxone given or just mentioned?

I don’t know, but if naloxone was given, too much was given.

Was haloperidol (Haldol) given or just mentioned?

I don’t know, but if haloperidol was given, not enough was given.

Here is a different example of excited delirium. This one was fatal. The patient was not attacking any of the police, he was only trying to keep from being restrained.
 


 

The treatment is sedation. Unfortunately, restraints generally need to be used to get the patient in a position where it is safe to give medication. A Taser is another way to stop the patient for long enough to get a lot of sedative into the patient.

Small doses kill, because they usually don’t even slow the patient down and may make the patient even more agitated. Yes, that is possible.

Excited delirium is a psychological and metabolic emergency. The metabolic emergency is what kills patients. This is not the time to try to get patients to tough it out the all-natural way.

Footnotes:

[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated link to PDF 7/23/2018.

[2] Philly Runners’ Deaths Point to Dangers of Extreme Stress on the Body – Between 6% & 17% of sudden cardiac deaths are associated with exertion
JEMS.com
Kia Gregory and Don Sapatkin
The Philadelphia Inquirer
Tuesday, November 22, 2011
Article

[3] Scopolamine Poisoning among Heroin Users — New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996
MMWR (Morbidity and Mortality Weekly Report).
Vol 45, No 22;457;
Free Full Text . . . . Free PDF

On March 16, 1995, eight persons were treated in the emergency department (ED) of a Bronx hospital for acute onset of agitation and hallucinations approximately 1 hour after “snorting” heroin. On physical examination, all these persons had clinical manifestations of anticholinergic toxicity (i.e., tachycardia, mild hypertension, dilated pupils, dry skin and mucous membranes, and diminished or absent bowel sounds); five had urinary retention. All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.

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