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E. D.
Excited Delirium
What is it?
How do we diagnose it?
How do we treat it?
E.D. is more then just agitation
Think Excited Delirium When Patient
Displays:
Sudden Bizarre Behavior
Hyperactivity
Combativeness
Super-Human Strength
Paranoid Delusions
Shouting
Hallucinations
Hyperthermia
Signs of Excited Delirium
Inability to Concentrate
Extreme Restlessness
Inability to remain still
Flailing
Diaphoresis
Flushed skin
Extreme Tachycardia
Shedding of clothes
Attraction to glass windows or mirrors
Statistically Speaking
Summer Months
High Heat and Humidity
High Body Mass Index
Stimulant Use
What causes Death in Excited
Delirium?
Positional Asphyxia is frequently blamed
and it is the most common position
patients are in before they suddenly die.
Patients are usually Hogtied or Hobbled
their hands tied behind their back to legs
This position makes it difficult for the
chest wall to expand and for the diaphragm
to contract. Thus breathing is difficult.
Positional Asphyxia
Restraint Asphyxia
Involves Take down of violent Individual
Arms are held behind the back
Chest is frequently compressed
Force on chest prevents Chest wall excursion
for breathing
Hobble Position
Why Does This Happen?
These patients are violent and are
forcibly restrained by multiple police
officers and end up prone on the
ground with multiple people leaning
or laying on them to stop their
combative behavior !
Stats on Positional asphyxia
LA County 216 Cases of Hobble Restraint Patient
Deaths in 2005 retrospective study.
-Majority Found Prone by EMS
-All had struggled with the Police
-All had developed labored breathing
-All had unanticipated sudden cardiac arrest
- None Survived
Hobble Position
• Hobble Position as a cause of death is
considered “controversial”.
• Effects of position on healthy volunteers in
inconclusive
• Healthy volunteers had decreased
pulmonary function values, but no hypoxia
Pathophysiology
• What Do We know about the
Pathophysiology of Sudden Death in
Excited Delirium ?
Lactate
• These patients are struggling, agitated,
flailing and have tremendous muscle
activity which produces large amounts of
lactic acid, which results in….
• Severe Metabolic Acidosis
Rhabdomyolysis
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Muscle Cells disintegrate
Release toxic components and electrolytes
Further alter acid base balance
Contribute to dangerous electrolyte
imbalances
Hyperkalemia
• Released from inside muscle cells
• Can cause cardiac dysrhythmias
• These dysrhythmias can lead to death
Hyperthermia
• These patients have been shown to have
temperatures of 106 degrees !
• No wonder they are frequently found naked
or shedding their clothes.
• The temperature alone could them
combative and irrational.
Hypoxia
The last nail in the coffin?
• Mix together stimulant use, acidosis,
electrolyte disturbances like hyperkalemia,
Rhabdomyolysis, hyperthermia and add
hypoxia and you get… sudden death?
Underlying Medical Conditions
• Things which place the patient at increased
risk of E.D. and sudden death with exertion:
• Cardiac Disease
• Lung Disease
• Psychiatric Conditions with mania or
psychosis
• Stimulant Use or Abuse
Management of Excited Delirium
• Assess for treatable causes hypoglycemia
and hypoxia
• Restrain
• Sedation
• Cooling
• Empiric Treatment for Metabolic Acidosis
• Rehydration
Assess for Treatable Causes
• Hypoglycemia
• Hypoxia
• Hyperthermia
Restraint
• Physical
• The patient must be restrained first, so you
don’t get hurt and they don’t hurt
themselves!
• Chemical
• The goal is chemical restraint to stop the
cascade of struggle, and metabolic
deterioration which leads to death !
Sedation !
• Benzodiazepines are most useful, large
doses well tolerated; Ativan & Versed.
• Haldol and Droperidol are not
recommended due to high risk of EPSExtra pyramidal Syndrome causing
uncontrolled muscle activity and speeding up
the metabolic spiral towards death, and
prolongation of QTc causing sudden death.
How to Give Sedation
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P.O. – Nope
I.M. - Okay
I.V. - Okay but risky
I.O. –Okay but dangerous
P.R.- Stinky and Slow
I.N.- Okay
I.M. , I.V. or I.N.
IM intramuscular route preferred.
IV intravenous okay if it can be done safely,
i.e. for the patient and the provider.
IN intranasal is another route being used by
some agencies.
Cooling
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Cooling is critical
IV Fluids
Limit Activity
Ice Packs Groin and axilla
Hypoglycemia
• Hypoglycemia must be watched for and
treated as a cause of delirium and a
complication of continued agitation
Dehydration
• These patients are hot, sweaty and have
extreme physical activity.
• IV hydration helps everything in their
metabolic crisis, acidosis, dehydration,
hyperkalemia and Rhabdomyolysis.
Hyperkalemia
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IV Fluids
Bicarbonate
Dextrose
Insulin
Miami Dade Protocol:
Excited Delirium E.D.
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Police contact EMS if:
Patient tasered by Police who fits E.D. criterion
Then Patient is:
Restrained by Police and then EMS takes over
Sedation with Nasal Versed then IV Versed
IV Bolus 2 liters of cold saline
Sodium Bicarbonate
Transport to ER with heads up call I..e E.D. Patient
enroute
The 2nd Annual Sudden Death, Excited Delirium & InCustody Death Conference
• Conference focusing upon the latest medical
research findings, theories, and legal issues about
excited delirium, sudden death, electronic control
devices, and jail suicide, which are of great
concern for law enforcement agencies around the
world, will be held on November 28-30, 2007 at
the Imperial Palace® Hotel, Las Vegas, Nevada.
The three-day Conference is sponsored by the
Institute for the Prevention of In-Custody Deaths.