Handout from a presentation at EMS Expo 2011. Most video and pictures removed.

1. Excited Delirium Michael Dailey, MD FACEPEMS Medical DirectorHudson Mohawk Region NY

2. My disclaimers: No financial conflicts of interest I am not a law enforcement officer – this is a physician’s perspective with deference and respect for my colleagues There is no way to cover this concept in the time allowed, but let’s try Opinions expressed are my own I have taken open-source material from the internet and places such as YouTube— I have credited sources when available— If you know of a credit I should have made, please let me know

3. Perspective Law enforcement Safety of public, person of concern and LEO Rapid control and restraint Dangerous? EMS Diagnosis and treatment when called to patient Risk from patient struggle Risk from sharps if ECW deployed

4. Who are we? Emergency Medical Technicians Paramedics Physicians Nurses Firefighters NOT cops – perspective here will not be law enforcement Our part of care begins when patient is physically restrained

5. Psychiatric calls and EMS Can we restrain? Can we protect ourselves? Who is responsible for the well-being of the person trying to injure us? We may have chemical restraint available, but how long does it take to work?

6. Excited Delirium Syndrome = ExDS Get excited about it, but keep each case boring and stay off the cover of the paper

7. Excited Delirium Syndrome = ExDS

8. Does ExDS Exist? If I didn’t think so, we wouldn’t be here People die in law enforcement custody. Some EMS may be able to help mitigate; some not… Cardiomyopathy Drug overdose/stimulant abuse Metabolic acidosis Positional restraint/asphyxia Excited delirium

9. Excited delerium 1650 appears in British literature 1849 Dr. Luther Bell (Bell’s Mania) described “acute exhaustive mania” inexplicable sudden death of psychotic 1985 Dr. Charles Wetli (Miami) coined “excited delirium” to explain sudden death associated with cocaine 1998 review of 21 cases of unexpected deaths in people in a state of “excited delirium” — 18 of which were people in police custody —all suddenly lapsed into tranquility shortly after restraint

10. Where is ExDS not found? AMA ICD-9 Coding Manual DSM-IV Not a single diagnosis: 10-12 different diagnosis codes can apply

11. DSM IV Criteria for Delirium A. Disturbance of consciousness (i.e., reduced awareness about the environment) with less ability to focus, sustain, or shift attention. B. A change in cognition (e.g., memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better explained by a … dementia. C. Develops over a short period of time (usually hours to days) and tends to fluctuate during the course of a day. D. Evidence from the history, examination, or laboratory findings that the disturbance is caused by direct physiologic consequences of a general medical condition.

12. What is ExDS? Delirium Agitation Combativeness Unexpected strength Elevated body temperature

13. What do these people look like? Psychological behavior Communication behavior Physical behavior Physical exam characteristics

14. Phases of the syndrome Delirium with agitation Sweating or appearance of high body temperature Acquiescence (Not mentioned in all sources) Respiratory compromise with potential respiratory arrest Cardiac arrest

15. General Rule: Medical versus psychiatric Consider all potential medical causes before pronouncing behavior either “just alcohol” or “just psychiatric” Danger to providers does not decrease based on etiology

16. Undifferentiated agitation Cocaine Methamphetamine Head trauma Intox (beer muscles) EtOHwithdrawal Psych

17. Can you tell the difference? Psychiatric agitation Sympathomimetic intoxication Cocaine or methamphetamine Alcohol Withdrawal or intoxication Hypoglycemia Head injury

18. Another disclaimer… I hate mnemonics! “I WATCH DEATH” – causes of delirium “TODS TIPS” – causes of altered mental status

19. “I WATCH DEATH” I = Infection W = Withdrawal from drugs A = Acute metabolic disorders T = Trauma C = CNS pathology H = Hypoxia D = Deficiency in vitamins E = Endocrinopathy A = Acute vascular insult T = Toxins H = Heavy metals

20. TODSTIPS T = Trauma, Acute head trauma O = Organ Failure, Cardiopulmonary, Renal, Neurologic, Hematologic, Endocrine D = Drugs S = Structural, Chronic subdural, Intracranial aneurysm, hydrocephalus, neoplasm or abscess

21. TODS TIPS T = Toxins, Plants, CO, Heavy metals, Industrials I = Infections, Sepsis, Meningitis, encephalitis, 3° syphilis, PNA, RMSF, etc P = Psychiatric, Thought disorders, Mood disorder S = Substrate Deficiency, Anoxia/hypoxia, Hypoglycemia, Wernicke-Korsakoff's (thiamine), Pellagra (niacin), Folic acid, Vitamin B12

22. Drugs (think “the anti’s”) Antineoplastics = Methotrexate Antiparkinsonian = Levodopa Antipsychotics Anti-cold = Antihistamine Antiobesity Other = Cimetidine, Thyroid hormones, Theophylline, Iron Drugs of abuse Antibiotics Anticholinergics Anticonvulsants Antidepressants Antiemetics Antihypertensives = Clonidine, Propranolol, Anti-inflammatory = Cyclosporin, NSAID, Steroid, Salicylate

23. Physiology of ExDS Similar to Neuroleptic Malignant Syndrome Hyper-excited Dopaminergic neurotransmitters Increased firing of neurons leads to: Increased muscular activity Increased agitation Increased movement Reduced cognition Reduced thermoregulatory ability

24. Physiology Stimulant abuse Hyperexciteddopaminergic neurons Metabolic acidosis Respiratory acidosis Hyperthermia Ultimately… Cascade or perfect storm All of the above combine for a disaster

25. Response to Excited Delirium Increased muscular activity leads to: Increased temperature Increased BP Increased HR Increased metabolic activity leads to: Increased lactic acid Increased RR to blow off carbon dioxide

26. Normal physiologic buffering CO2 + H2O = HCO3- + H+ pH 7.4

27. Normal exertional buffering CO2 + H2O = HCO3- + H+ pH nl RR

28. Drug induced exertional buffering CO2 + H2O = HCO3- + H+

29. Chest compression exertional buffering pH RR

30. So what do the AHA guidelines say? Epi? Amiodarone? Lidocaine? Shock? Why 2 minutes of CPR?

31. What do I do? I am a physician—I write protocols… Remember AHA ACLS is a guideline Created by committee Evidence based Consensus of experts when no evidence NO evidence in this case

33. Lewis case from Palm Beach Horrible case: COPS was riding along I found this video on YouTube, but no clean copy http://blogs.browardpalmbeach.com/juice/2009/03/police_and_city_of_wpb_off_the.php http://www.wpbf.com/news/10547880/detail.html My sympathy to the officers and the Lewis family

34. What should we do?

35. LEO Perspective “Leave me alone so I can do my job” “Doc, don’t give me shit, you don’t know what it is like out there” “This guy was just beating me up, so I’m not giving him an inch” “Oh, shoot, you mean you aren’t going to get me in trouble…” “Oh, this is to protect me…”

36. EMS Perspective Patient in custody is struggling How much is too much Sedation When to give mild sedation When to give high doses of sedation Should we check temperatures Acute deterioration Should we give bicarb?

37. Principles of care in delirium Protect the staff Protect the person / patient Facilitate rapid diagnosis and management

38. Consequences Rapid death Positional asphyxia Arrhythmias Hyperthermic death Untreated illness and morbidity

39. RODEOS Restraint Oxygen Detrose Examination (PE, EKG, etc) Observation Serial assessment

40. Restraint Physical restraint is temporizing Follow with medication / chemical restraint ASAP

41. Restraints Anything that doesn’t get tighter Multiple people as a team Back away if resources not available Follow physical with chemical – not medically prudent to allow struggle Systematic review of assessment measures and pharmacologic treatment Clinical therapeutics

42. Control goals Understand drugs and understand what is happening with the human being Principle very sick, may need IV IM vs IV vsblowdart What should endpoint be? Sedation? Or checking VS? Checking blood sugar?

47. Choose the right drug Psychiatric or emotional cause Antipsychotic Withdrawal or sympathomimetic Benzodiazepine Unknown Benzodiazepine

48. Dopamine and delirium Dopamine pathways are implicated Chronic cocaine up-regulates dopamine receptors Cocaine and other sympathomimetics release dopamine as a neurotransmitter Turning up the heat… Need to “turn down” the neurotransmitters

49. Why benzodiazepines? Enhance GABA GABA (Y-aminobutyric acid) is an inhibitory neurotransmitter that reduces dopamine release Increase GABA, decrease dopamine; thus, excitement is decreased Turns on the AC…

50. Benzodiazepines Limited resp depression But potential obstructive problem if flat on back …unless alcohol involved then potential problem BEWARE supplemental oxygen how low can they go… watch ventilatory status Midazolam has most rapid onset of action IM or IN

51. What about the old…5 and 2? Haloperidol 5 mg mixed with Lorazepam 2 mg Single syringe IM Is it really that bad? “This cocktail proves you understand neither pharmacology, nor physiology” Bob Hoffman, MD FACEP, FACET, Director NYC Poison Control Center

52. Haloperidol - Haldol Anticholinergic, so it actually decreases ability to thermoregulate Decreases seizure threshold Black box for QT prolongation Not faster than benzodiazepines

53. Now what?

54. What if they go into cardiac arrest? Uninterrupted compressions PEA Sodium bicarbonate – 2 amps Asystole Sodium bicarbonate – 2 amps Ventricular fibrillation Sodium bicarbonate – 2 amps Hold on initial shock for 2 minutes Hold on initial epinephrine

55. Who dies in custody without trauma? 97% between 34 – 44 11% chemical spray 8% impact weapons 27% ECD weapons 63% struggle with LEO 53% ingested street drugs 60% exhibited bizarre behavior Jeff Ho,Policemag, Aug 2005

56. Recognition Any case that begins as bizarre presentation Another “EDP” call An “assist the police” Intox or drugged up Naked patients should always be a significant concern…

57. Take home message If everything goes well, these calls are boring If all goes badly reach for bicarb first Prevention is key, work with law enforcement Early chemical restraint is the key to safety Safest agents are benzos, but use them safely—constant monitoring

60. Thank you.Questions, thoughts or comments: mwd101@gmail.com