Excited Delirium. Objectives. Case 4/28/2015

Transcription

1 Excited Delirium Patrick Cody, DO, MPH, FACOEP Norman Regional Health System Objectives Review the history of Excited Delirium Syndrome (ExDS) Understand the diagnostic features of this disease Review the treatment of ExDS Case A 22 year old male presents to the emergency department via ambulance for a complaint of anxiety. He admits to using methamphetamine on a regular basis. His symptoms are vague and non-specific. Basic labs are ordered, as well as IV fluids and ativan. The nurse leaves the room to get the medication, when he returns the patient is missing from the room. 1

2 Case (continued) A short time later a crazy person is found wandering the hospital property. He does not follow commands presented to him by PD. He is tased without results. He arrives via ambulance. Several emergency personnel are struggling with the patient when he arrives. PD performs a lateral vascular restraint which is followed by cardiopulmonary arrest. Case conclusion He is intubated and resuscitated after a short time. Immediately following resuscitation his ph is 6.7 (CO2 was normal 1 hr before), CK is After a prolonged ICU stay, he is ultimately discharged to a nursing facility. History First described more than 150 years ago Institutionalized patients Mentally disturbed Pharmacology lacking 2

3 History Luther Bell - McLean Asylum for the Insane (Massachusetts) Bell s mania American Journal of Insanity 75% case fatality rate Followed uncontrolled psychiatric illness 1950s Drastic decline History Modern antipsychotic pharmaceutical therapy Less institutionalization 1980s Uptick Associated with abuse of cocaine in North America Cocaine, meth, pcp Excited Delirium coined in 1985 Incidence difficult to determine No standardized case definition Semantics in Coding Diagnosis of exclusion on autopsy Little documentation regarding survivors Epidemiology 3

4 Autopsy case reports 95% fatalities are male Mean age 36 Hyperaggressive, impervious to pain, combative, hyperthermic, tachycardic Struggle with law enforcement Physical, noxious chemical, TASER use Period of quiet followed by sudden death Case reports (continued) Most cases involve stimulant abuse Cocaine most common Other stimulants implicated Psychiatric illness smaller cohort Abrupt cessation of psychotherapeutic drugs Withdrawals? Central nervous system adaptation? Clinical Features Feature Frequency (95% CI) Pain tolerance 100 (83-100) Tachypnea 100 (83-100) Sweating 95 (75-100) Agitation 95 (75-100) Tactile Hyperthermia 95 (75-100) Police noncompliance 90 (68-99) Lack of tiring 90 (68-90) Unusual strength 90 (68-90) 4

5 Pathophysiology Short story: WE DON T KNOW More questions than answers Mechanism of progression unknown Risk factors for death unknown Pathophysiology What we DO Know Associations include: Stimulant drug use Psychiatric disease Psychiatric medication withdrawl Metabolic disorders Cocaine Levels usually less than OD Similar to recreational drug users Dopamine Pathophysiology Loss of dopamine transporter in the striatum Hypothalamic dopamine receptors are responsible for thermoregulation Cardiac Bradysystole Ventricular dysrhythmias are rare 5

6 Clinical Characteristics Pathway not understood well Described by epidemiology, usual course Minimal required features to make diagnosis: Delirium and excited or agitated state Symptom cluster will vary Different instigators Occurs Suddenly Death Typically follows physical control measures (remember our case) Recurrent features Male subjects Avg age 36 Destructive or bizarre behavior Psychostimulant drug intoxication Psych illness history Nudity or inappropriate clothing Failure to respond to PD presence (delirium) Erratic/violent behavior Unusual strength and stamina Ongoing struggle CV collapse following struggle or after quiescence Inability to be scene 6

7 Ddx Any: Drug Toxin Extraneous substance Any: Psychiatric or medical conditions Any: Biochemical or physiologic alterations DdX for Altered Mental Status AEIOU TIPS Alcohol Endocrine, Encephalopathy, Electrolytes Insulin (hypoglycemia) Oxygen, Opiates (Other drugs) Uremia Toxins, Trauma, Temp Infection Psych Stroke, Shock, SAH, Space occupying lesion Mimickers of ExDS Hypoglycemia Violent outbursts, appearance of intoxication FSBS solves the mystery Heat Stroke Tactile hyperthermia Rhabdomyolysis Delirium May be associated with mental illness 7

8 Mimickers of ExDS Psychiatric Issues Drug withdrawal or non-compliance Substance abuse common in psych patients Acute paranoid schizophrenia Sudden Death Causes Ischemic or drug induced Stress cardiomyopathy Long QT syndrome Brugada syndrome Cannon s Voodoo death Lethal Catatonia Sudden unexplained death in epilepsy Recognition is key Treatment Avoid physical control measures Catecholamine surge Metabolic acidosis Safety Net When safe IV, O2, Monitors, FSBS 8

9 Treatment Agitation Benzos, Antipsychotics, Ketamine IV route preferred May not be safe to involve needles (IN) Doses are recommendations only Lacking hard data Benzos Routes Dose (mg) Onset (min) Duration (min) Versed IN IM IV Ativan IM IV Valium IM IV Antipsychotics Haldol Droperidol Geodon (Ziprasidone) Zyprexa (Olanzapine) Route IM IV IM IV Dose (mg) Onset (min) IM Duration (min) IM hrs 9

10 Antipsychotics Pitfalls: Prolonged QTc Risk for sudden cardiac death Anticholinergic potentiation Ketamine Benefits: Rapid onset Lack of significant CV/Resp effects Pitfalls (rare): Oral secretions Laryngospasm HTN Emergence phenomenon Route Dosing (mg/kg) Onset (min) Duration (min) IM IV Provider discretion RSI May be required to control the situation 10

11 Hyperthermia Passive Removal from warm environment Removal of clothes Active Misting Evaporative cooling Ice packs IVF Bicarb Acidosis/ Rhabdomyolysis Controversial Efficacy unknown Some EMS agencies use it empirically (rhabdo) Try not to interfere with hyperventilation Often Involved Law Enforcement Person with ExDS has deteriorated to the point PD is called Has to: Recognize medical emergency Attempt to control irrational and physically resistive person Keep everyone safe 11

12 Law Enforcement High Risk Injury/death to the officer ExDS subject has potentially lethal condition Public Relations Perfect outcomes expected Public scrutiny of in-custody deaths What should officers do? Recognize that subjects: Have an acute, life threatening medical condition Lack understanding, normal fear, rational thoughts Are violent and impervious to pain What should officers do? Traditional tactics WILL fail: Pepper spray Impact batons Joint lock maneuvers Punching, kicking 12

13 What should officers do? GOALS: Recognize ExDS Contain Subject Quickly take into custody Turn care over to EMS ASAP Document temperature ASAP To support that PD intervention was independent of death Goals: Recognize ExDs Request more officers EMS Have duty to provide timely care while maintaining safety Summary Identification is important Early intervention with sedation Minimize physical stress We don t know who will die Even when we do everything right Good documentation on our part Help Researchers High liability situation. 13

14 Reference DeBard, Et. Al, ACEP Excited Delirium Task Force. White Paper Report on Excited Delirium Syndrome. September Thanks 14