What is it? How do we diagnose it? How do we treat it?

1. What is it?How do we diagnose it?How do we treat it? E. D. Excited Delirium

2. E.D. is more then just agitation

3. Think Excited Delirium When Patient Displays: Sudden Bizarre Behavior Hyperactivity Combativeness Super-Human Strength Paranoid Delusions Shouting Hallucinations Hyperthermia

4. 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

5. Statistically Speaking Summer Months High Heat and Humidity High Body Mass Index Stimulant Use

6. 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.

7. 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

8. Hobble Position

9. 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 !

10. 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

11. 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

12. Pathophysiology What Do We know about the Pathophysiology of Sudden Death in Excited Delirium ?

13. 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

14. Rhabdomyolysis Muscle Cells disintegrate Release toxic components and electrolytes Further alter acid base balance Contribute to dangerous electrolyte imbalances

15. Hyperkalemia Released from inside muscle cells Can cause cardiac dysrhythmias These dysrhythmias can lead to death

16. 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.

17. HypoxiaThe last nail in the coffin? Mix together stimulant use, acidosis, electrolyte disturbances like hyperkalemia, Rhabdomyolysis, hyperthermia and add hypoxia and you get… sudden death?

18. 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

19. Management of Excited Delirium Assess for treatable causes hypoglycemia and hypoxia Restrain Sedation Cooling Empiric Treatment for Metabolic Acidosis Rehydration

20. Assess for Treatable Causes Hypoglycemia Hypoxia Hyperthermia

21. 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 !

22. Sedation ! Benzodiazepines are most useful, large doses well tolerated; Ativan & Versed. Haldol and Droperidol are not recommended due to high risk of EPS- Extra pyramidal Syndrome causing uncontrolled muscle activity and speeding up the metabolic spiral towards death, and prolongation of QTc causing sudden death.

23. How to Give Sedation P.O. – Nope I.M. - Okay I.V. - Okay but risky I.O. –Okay but dangerous P.R.- Stinky and Slow I.N.- Okay

24. 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.

25. Cooling Cooling is critical IV Fluids Limit Activity Ice Packs Groin and axilla

26. Hypoglycemia Hypoglycemia must be watched for and treated as a cause of delirium and a complication of continued agitation

27. Dehydration These patients are hot, sweaty and have extreme physical activity. IV hydration helps everything in their metabolic crisis, acidosis, dehydration, hyperkalemia and Rhabdomyolysis.

28. Hyperkalemia IV Fluids Bicarbonate Dextrose Insulin

29. Miami Dade Protocol: Excited Delirium E.D. 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

30. The 2nd Annual Sudden Death, Excited Delirium & In-Custody 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.