excited delirium

1. Excited Delirium
The dangers of synthetic
drugs today

4. Bath Salts
 The synthetic cathinone products marketed as “bath salts” to
evade detection by authorities should not be confused with
products such as Epsom salts that are sold to improve the
experience of bathing.
 Bath salts typically take the form of a white or brown
crystalline powder and are sold in small plastic or foil
packages labeled “not for human consumption.” Sometimes
also marketed as “plant food”— or, more recently, as “jewelry
cleaner” or “phone screen cleaner”— they are sold online
and in drug paraphernalia stores under a variety of brand
names, such as “Ivory Wave," "Bloom," "Cloud Nine," "Lunar
Wave," "Vanilla Sky," "White Lightning," and “Scarface.”

5. How Are Bath Salts Abused?
Bath Salts are typically taken
orally, inhaled, or injected, with the
worst outcomes being associated
with snorting or needle injection.

6. The Chemical Reaction
 The energizing and often agitating effects reported in people
who have taken bath salts are consistent with other drugs
like amphetamines and cocaine that raise the level of the
neurotransmitter dopamine in brain circuits regulating
reward-motivated behavior and movement. A surge in
dopamine in these circuits causes feelings of euphoria and
increased activity. A similar surge of the transmitter
norepinephrine can raise heart rate and blood pressure.
 The hallucinatory effects often reported in users of bath salts
are consistent with other drugs such as MDMA or LSD that
raise levels of another neurotransmitter, serotonin.

7. Your Body’s Response to Bath
Salts
 Common reactions from Bath Salts include cardiac
symptoms (such as racing heart, high blood pressure, and
chest pains) and psychiatric symptoms including paranoia,
hallucinations, and panic attacks.
 Patients with the syndrome known as “excited delirium” from
taking bath salts also may have dehydration, breakdown of
skeletal muscle tissue, and kidney failure

8. Man on left was on bath salts, man
on right was his victim

9. The result of his assault while on
Bath Salts

10. Songs that reference MOLLY!
PUSH PLAY

11. MOLLY
 MDMA (3,4-methylenedioxy-methamphetamine), popularly
known as ecstasy or, more recently, as Molly, is a synthetic,
psychoactive drug that has similarities to both the stimulant
amphetamine and the hallucinogen mescaline. It produces
feelings of increased energy, euphoria, emotional warmth
and empathy toward others, and distortions in sensory and
time perception.

12. How is Molly Abused
 MDMA is taken orally, usually as a capsule or tablet. The
popular term Molly (slang for “molecular”) refers to the pure
crystalline powder form of MDMA, usually sold in capsules.
The drug’s effects last approximately 3 to 6 hours, although it
is not uncommon for users to take a second dose of the drug
as the effects of the first dose begin to fade. It is commonly
taken in combination with other drugs.

13. The Chemical Reaction
 MDMA acts by increasing the activity of three
neurotransmitters, serotonin, dopamine, and norepinephrine.
The emotional and pro-social effects of MDMA are likely
caused directly or indirectly by the release of large amounts
of serotonin, which influences mood (as well as other
functions such as appetite and sleep). Serotonin also triggers
the release of the hormones oxytocin and vasopressin, which
play important roles in love, trust, sexual arousal, and other
social experiences.

14. Your Body’s Response to Molly
 The surge of serotonin caused by taking MDMA depletes the brain
of this important chemical, however, causing negative after effects—
including confusion, depression, sleep problems, drug craving, and
anxiety—that may occur soon after taking the drug or during the
days or even weeks thereafter.
 MDMA can have many of the same physical effects as other
stimulants like cocaine and amphetamines. These include increases
in heart rate and blood pressure, which are particularly risky for
people with circulatory problems or heart disease. MDMA users may
experience other symptoms such as muscle tension, involuntary
teeth clenching, nausea, blurred vision, faintness, and chills or
sweating.
 In high doses, MDMA can interfere with the body’s ability to regulate
temperature. This can lead to a sharp increase in body temperature
(hyperthermia), which can result in liver, kidney, or cardiovascular
system failure or even death.

15. Milk is NOT what he needs

16. “Flakka” (Alpha – PVP)
 Use of a dangerous synthetic cathinone drug called alpha-
pyrrolidinopentiophenone (alpha-PVP), popularly known as
"Flakka," is surging in Florida and is also being reported in
other parts of the country.
 Alpha-PVP is chemically similar to other synthetic cathinone
drugs popularly called "bath salts," and takes the form of a
white or pink, foul-smelling crystal.

17. How is Flakka Abused
 Flakka can be eaten, snorted, injected, vaporized in an e-
cigarette or similar device, or smoked in a joint. Vaporizing,
which sends the drug very quickly into the bloodstream, may
make it particularly easy to overdose.

18. The Chemical Reaction
 The chemicals in Flakka, bind and prevent molecules on the
surface of neurons, that normally keep the levels of mood-regulating
neurotransmitters, dopamine and serotonin, in check. The result is
to "flood the brain" with these chemicals. Cocaine and
methamphetamine have similar modes of action in the brain, but the
chemicals in Flakka have longer-lasting effects.
 Although a typical Flakka high can last one to several hours, it is
possible that the neurological effects can be permanent. Not only
does the drug sit on neurons, it can also destroy them. And
because Flakka, like Bath Salts, hangs around in the brain for
longer than cocaine, the extent of the destruction can be greater.
 Another serious, potentially lingering side effect of Flakka is the
effect on kidneys. The drug can cause muscles to break down, as a
result of hyperthermia, taking a toll on kidneys. Experts worry that
some survivors of Flakka overdoses may be on dialysis for the rest
of their lives.

19. Your Body’s Response to Flakka
 Like other drugs of this type, alpha-PVP can cause a
condition called "excited delirium" that involves hyper-
stimulation, paranoia, and hallucinations that can lead to
violent aggression and self-injury. The drug has been linked
to deaths by suicide as well as heart attack. It can also
dangerously raise body temperature and lead to kidney
damage or kidney failure.

21. Signs and Symptoms of the
“Excited Delirium” Patient
 Moderate to severe Paranoia
 Extreme Agitation/ violent behavior
 Shouting or making animal noises
 Increased Strength (SUPER HUMAN STRENGTH)
 Elevated Body Temperature/ Hyperthermia
 Severe Panic/ “Bug Eyes”
 Insensitivity to pain
 Increased Thirst/ Seeking Water
 Naked
 Attraction and/or violence toward glass and reflective
surfaces

22. Medical Issues that can mimic
Excited Delirium
 Panic Attacks
 Postictal State following a seizure
 Diabetic emergency
 Head injury
 DT’S
 Hyperthyroidism
 Infection/ Sepsis
 Sickle Cell crisis with Chest Pain and SOB

23. TREATING EsDX
 Do not approach patient until scene is secured by LEO.
 Have sufficient assistance available to manage patient.
 Initial Patient Assessment Protocol 2.1.1 when able to control patient.
 Airway Assessment/Management Protocol 2.1.2
 Rule out other medical issues.
 If attempts at verbal control are unsuccessful, use reasonable physical
 Use restraints until such time as patient can be medicated
 Every attempt should be made to avoid injury to the patient when using
physical restraint. If necessary, use standard restraining techniques and
devices. Use sufficient padding on extremity restraints on elderly patients
or others with delicate skin.
 Do NOT “hog tie” patient. Transport on side or supine . If needed have
LEO ride in the back of the ambulance.
 Communicate in a calm non threatening manner.
 Attach cardiac monitor and pulse ox as soon as possible.

24. Chemical Sedation
Haldol
(Haloperidol)
An antipsychotic
medication. It is used
in the treatment of
schizophrenia, acute
psychosis, mania,
delirium and other
disorders.
Versed
(Midazolam)
Is a short-acting
central nervous
system (CNS)
depressant of the
benzodiazepine
class.Used for
sedation in ExDS
patient management.
Benadryl
(dipenhydramine)
An antihistamine
possessing sedative
properties that is
mainly used to treat
allergies. Is
commonly used as a
sleep aid.
The Big Three

25. ALS Level 1: Paramedic Only
 If not possible to safely manage patient due to hyper-aggression and agitation, administer one of the
following:
 Versed 2 – 4 mg IM / IN via atomizer (or IV if able to safely get an IV) may repeat 3 – 5
minutes PRN up to 10 mg.
 Diazepam (Valium) 5 – 10 mg IM (or Iv if able to safely get an IV) may repeat x 1 PRN.
 Haldol 5 – 10 mg IM (DO NOT GIVE HALDOL IV) followed by Diphenhydramine (Benadryl)
25 IM or IV. Must be on cardiac monitor.
 NOTE: IF Haldol unavailable OR per Med Control: Ketamine
(Ketalar) 5 mg/kg IM x 1. Watch for hypersalivation/increased
bronchial secretions. Give Atropine 0.5 mg IV/IO every 5
minutes (Ketamine is on FireMed1 or Rescue 10)
to maximum of 0.04 mg/kg or 3 mg total
After sedation, If IV has not been established before, start IV of Lactated Ringers or
NS at KVO. Bolus with 250 ml increments as needed for systolic BP <90 mm Hg
and/or HR > 120.
If altered mental status, and when safe to so, determine serum glucose level with
glucometer. For abnormal BGL, refer to Hyperglycemia/Hypoglycemia Protocol.

26.  Consider Benzodiazapines (Versed, Valium) after patient is sedated
and restrained and IV access established for continued sedation if
needed with respiratory and cardiac in place.
 If altered mental status, and when safe to do so, determine serum
glucose level with Glucometer or DextroStix:
If sugar 60 mg/dl - 80 mg/dl; give; 100 ml 10% Dextrose IV or
Glucagon 1mg IM or Sublingual glucose paste, May repeat x 1 if
after 15 minutes recheck fingerstick glucose < 80 mg/dl
If Blood sugar < 60 mg/dl; 100 - 250 ml 10% Dextrose IV or
Glucagon 1 mg IM
If glucose > 80 mg/dl and < 200 mg/dl, provide supportive care,
keep NPO
If glucose > 200 mg/dl, go to Hyperglycemia Protocol

27. If body temperature exceeds 102 F, move patient
to cooler environment ad remove clothing. Cool
aggressively with wet sheets, cool packs, and/or
evaporative airflow. Lower body temperature to
102 F (39 C).
If patient goes into cardiac arrest, treat accordingly
and administer 1 amp Sodium Bicarb.
Monitor any physically or chemically restrained
patient closely for respiratory compromise and
plan to intervene accordingly.

28. Monitor, Reassess, Treat, Monitor, Reassess and Treat some more!
Pulse Oximetry: Measurement of
Oxygen saturation in the blood.
Electrocardiogram (EKG):
Monitoring of the heart rhythm.
Temperature: Monitor initial
temperature and measure
decrease during cooling.
End-Tidal Capnography:
Measurement of Carbon Dioxide
partial pressure during exhalation.
Automatic Blood Pressure, Pulse
and Respirations through the
LifePack Monitor/Defibrillator.
Mental Status
Correct and Timely Medical Management Can Save Lives