By Drew Johnson
EMS1 Editor
Excited delirium is a problem that both cops and medics have to face.
In fact, it’s a problem that medics and cops have to face together, Michael Dailey, the Medical Director of the Hudson Mohawk Region EMS said in a session at EMS World Expo Thursday in Las Vegas.
“Our job starts where law enforcement’s stops, which isn’t to say cops won’t still be on the scene,” he said. Law enforcement’s main priority is to seek safety for the public and the patient, gain control of the scene, and asses the level a danger posed by a patient.
Once that’s done, medics step in.
Causes and signs
“There are a lot of things that make people delirious, and we need to find out what they are quickly to start mitigating the damage,” Dailey said.
Psychiatric patients put medics in very different situations than typical EMS patients. “It’s hard to know which way to go with excited delirium patients. We can’t tie them up and we can’t hit them. It’s very difficult to make sure you’re absolutely safe and patients are safe,” Dailey said.
There was a spike in cases of excited delirium in the 1980s and 90s caused, unsurprisingly, by a boom in the abuse of cocaine and methamphetamine, but Dailey emphasized that excited delirium isn’t a single syndrome.
Hallmarks of these cases include a disturbance of consciousness, change in cognition, and behavior that developed over a short period of time.
When assessing potential excited delirium patients, medics should also look for:
- Delirium
- Agitation
- Combativeness
- Unexpected strength
- Elevated body temp
An important symptom that Dailey said isn’t mentioned in much of the research about excited delirium is acquiescence. When someone is fighting and struggling, and then all of a sudden quits, that’s a problem, he said.
Left untreated, the range of conditions that encompass excited delirium will lead to respiratory compromise with the potential for respiratory arrest and/or cardiac arrest.
Secure and control
First and foremost, Dailey said, medics (usually with the help of law enforcement) have to get excited delirium patients secured. It’s important not to use restraints that continually tighten, as these patients will struggle enough to do themselves harm.
One thing to absolutely avoid is piling on a patient, which runs the risk of causing positional asphyxia and further respiratory issues.
Once secured, patients should be double-handcuffed (one cuff on each wrist) to the backboard (not the stretcher) and strapped down at the thorax, hips, and knees. Doing so leaves the team able to treat with intramuscular drugs, have access to the airway, and start an IV line if necessary.
Treatment protocols
Because excited delirium can be caused by a range of conditions, treatment will vary on a case by case basis, Dailey said. Medics shouldn’t assume that drug overdose or alcohol abuse is always the cause – head trauma and diabetes are also potentially conditions of some excited delirium cases.
Chemical restraint is often necessary, and Dailey’s drug of choice in these cases is benzodiazepines. “I use intramuscular Versed (Midazolam) because it’s the most rapidly absorbed with the most well understood dose response,” he said, adding that medics who use this drug should watch out for respiratory depression.
If a patient goes into cardiac arrest following a struggle, Dailey advocates the use sodium bicarbonate to offsets the profound acidosis that is common with excited delirium patients.
Keep these cases boring
Prevention is key in keeping excited delirium cases from elevating to the point of cardiac or respiratory arrest, and EMS must work with their local police system to develop a plan for catching these patients before they get out of hand.
“Find these cases early,” Dailey said. “Look for cases that begin as a bizarre presentation. Look for an EDP call or an ‘assist the police’ call.”
The real idea, Dailey said, is to keep these cases boring. “Ideally, you want excited delirium cases to be exciting enough to get medics focused and working in concert with law enforcement, but not exciting enough to reach the front page of the newspaper.”