ems medicine live!€¦ · ems medicine live • zoom – during presentation • everyone will be...
TRANSCRIPT
4/29/2015
1
EMS Medicine Live!
WelcomeWelcome
Fourth EMS Webinar
4/29/2015
2
EMS Medicine Live!
• VisionVision– Community & Academic EMS Physician
Education• Information Sharing• Board Preparation
– Group involvementp• Meet and see our peers• Involve your unique experiences and skills
EMS Medicine Live!Course Directors
Ch i ti K t MD MPHChristian Knutsen, MD, MPH
Derek Cooney, MD
Brian Clemency, DO
4/29/2015
3
EMS Medicine Live
• ZoomZoom– During presentation
• Everyone will be muted• Chat questions to Knutsen to be answered either
during or at the end of the presentation• Raise hand virtually in chat window
– RecordingRecording• Upstate will record and post conferences online• You can record at your site also
EMS Medicine Live
• Zoom• Zoom– Questions
• Questions at the end– Unmute yourself to ask a question or
– Message Knutsen if you have a question and I’ll ask for questions in order.
4/29/2015
4
EMS Medicine Live
• Zoom• Zoom– Technical Problems?
• Message me if you have a suggestion.
• If you have a serious problem, email [email protected]
EMS Medicine Live
• Speaker• Speaker
Christian Knutsen
4/29/2015
5
Excited Delirium and Sudden In Custody Death
Christian Knutsen
Excited Delirium
• What ExD is not• What ExD is not– Not universally recognized condition
– Not a medical diagnosis
No ICD-9 code
AMA does not recognize
– Not a psychiatric diagnosis
No DSM V
4/29/2015
6
Excited Delirium
• What ExD is• What ExD is– Descriptive Syndrome
– Accepted by ACEP/ED physicians, medical examiners, EMS, Police, Press
– You know it when you see it
Excited Delirium
• Appleton police encounter Wisconsin• Appleton police encounter, Wisconsin
4/29/2015
7
Excited Delirium
Three Componentsp
• Delirium
• Psychomotor Agitation
• Physiologic Excitation
Excited Delirium
Clinical Findings:g• Agitated, Combative, Bizarre
• Pain Tolerance
• Super-Human Strength
• Hyperthermic, Sweating
• Naked
• Tachycardia, Tachypnea
• Hallucinations, ParanoiaHallucinations, Paranoia
• Attack objects
• Fight to exhaustion
• Police noncompliance
4/29/2015
8
Excited Delirium
• Hyperthermiayp
• Metabolic Acidosis
• Rhabdomyolysis
• Multisystem Organ Failure
Excited Delirium
Historyy• 1650 appears in British literature• 1849 Dr. Luther Bell (Bell’s Mania)
– “Acute exhaustive mania” – 75% mortality in institutionalized psychotic patients
• 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 “e cited deliri m” 18 of hich ere peoplein a state of “excited delirium” — 18 of which were people in police custody —all suddenly lapsed into tranquility shortly after restraint.
4/29/2015
9
Excited Delirium
EtiologyEtiology– Stimulant Abuse
– Psychiatric Disease
– Other
– Combination
Excited DeliriumEtiology
Traditional StimulantsTraditional Stimulants
• Cocaine
• PCP
• Methamphetamines
4/29/2015
10
Excited DeliriumEtiology
Designer StimulantsDesigner Stimulants
• Synthetic Cathinones
• Synthetic Cannabinoids
Excited DeliriumEtiology
Synthetic CathinonesSynthetic Cathinones
4/29/2015
11
Excited DeliriumEtiology
Synthetic CathinonesSynthetic Cathinones
Excited DeliriumEtiology
• Khat (Catha edulis)– Flowering Plant
– Native to East Africa and Arabian Peninsula
– Popular in Somalia, Yemen
4/29/2015
12
Excited DeliriumEtiology
• Natural Cathinone• Natural Cathinone– Euphroia
– Alertness
– Hallucinations
Excited DeliriumEtiology
• Synthetic Cathinone• Synthetic Cathinone– First Developed 1920s
• Methcathinone
– Medical Uses• Antidepressants?
A i S ?• Appetite Suppressants?
4/29/2015
13
Excited DeliriumEtiology
• Synthetic Cathinone• Synthetic Cathinone– Medical Uses
• Bupropion (Wellbutrin, Zyban)– Antidepressant, Smoking Cessation
Excited DeliriumEtiology
• Similar to ecstasy and amphetamines• Similar to ecstasy and amphetaminesMDMA, Ecstasy
Methylone
4/29/2015
14
Synthetic Cathinones
Excited DeliriumEtiology
Synthetic CathinonesAuraBlack RobBlissBlizzardBloomBlue SilCharge Cloud 9DroneH i Ch li
Lovey DoveyLunar WaveMaddieMCATMeow MeowMonkey DustMTVOcean SnowPeeveP l W
ScarfaceSextasySnow LeopardStardustSuper CokeVanilla SkyWhite LightningWhite RushWhite LadyZHurricane Charlie
Ivory WavePurple WavePVRed Dove
Zoom
Excited DeliriumEtiology
• Synthetic Cathinones• Synthetic Cathinones– Flakka
– Gravel
4/29/2015
15
Excited DeliriumEtiology
Excited DeliriumEtiology
4/29/2015
16
Excited DeliriumEtiology
Excited DeliriumEtiology
SyntheticSynthetic Cannabinoids
4/29/2015
17
Excited DeliriumEtiology
SyntheticSynthetic Cannabinoids
– THC Analogs
– K2 and Spice• Better High?
• Legal Ambiguity?
Excited DeliriumEtiology
SyntheticSynthetic Cannabinoids
– THC Analogs
– K2 and Spice• Bag of plant material
• Sprayed with drug
• Labeled “Not For Human Consumption”
4/29/2015
18
Excited Delirium
• Recently in Syracuse…Recently in Syracuse…– Spike in synthetic
cannabinoids cases• ~15-20 patients per days• High agitated, combative• Straining Police, EMS,
ED staff
Synthetic cannabinoids– Synthetic cannabinoids mixed with synthetic cathinones?
Excited Delirium
• Type 1 • Type 2yp– Bradycardic– Mild Hypotension– Lethargic/Coma– Agitation with
stimulation– ±Seizures– 5-10 mg Versed
yp– Tachycardic– Hypertensive– Highly agitated– Highly combative– Large pupils– ±Seizures– High dose benzosg
– Intubation due to sedations and airway protection
High dose benzos– Intubation for patient
control
4/29/2015
19
Excited DeliriumEtiology
Psychiatric DiseasePsychiatric Disease – Untreated exacerbation of illness
– New onset psychiatric illness
– Suddenly stopping psychiatric medications• Withdrawal Syndrome?
• CNS adaption of therapy?
• Reemergence of underlying disease
Excited DeliriumEtiology
• Medical • TraumaMedical– Sepsis– Meningitis– Encephalitis– Diabetes– Other endocrine
St k
Trauma– Head injury– Hypoxia– Hypovolemia
• Toxicology– Stroke– Dementia– Medications
– Alcohol
4/29/2015
20
Excited DeliriumManagement
Principles of carePrinciples of care– Protect your team!
EMTs, paramedics, ED techs, nurses, residents, other providers, and yourself!
– Protect the patient
Facilitate rapid diagnosis and management
4/29/2015
21
Excited DeliriumManagement
RODEOSRODEOS• Restraint• Oxygen• Detrose• Examination (PE, EKG, etc)• Observation• Serial assessment
Excited DeliriumManagement
Physical restraintPhysical restraint – Temporizing
– Anything that doesn’t get tighter
– Multiple people as a team
– Back away if resources not available
4/29/2015
22
Excited DeliriumManagement
Chemical restraintChemical restraint – IV, IO, IM, IN, Blow Dart
– Options• Benzodiazepines
• Antipsychotics
K i• Ketamine
Excited DeliriumManagement
Chemical restraintChemical restraint – Intubation
• Indications– Significant coma, airway protection
– Unable to control with sedatives safely
– Escalating doses of sedatives
• Hyperventilation?
• High dose sedation
4/29/2015
23
Excited DeliriumManagement
• ExaminationExamination– Trauma?– EKG changes? Hyperkalemia, Long QTc– CMP, CK, Troponin
• Observation & Metabolize To FreedomAd i ivs. Admission
• Serial assessment
Excited DeliriumManagement
CoolingCooling– Follow core temperature
– Sedation helpful
– Paralysis? Continuous EEG?
– IVF
– Cooling Blanket, Fans
– Cold packs
4/29/2015
24
Excited DeliriumManagement
Prehospital CarePrehospital Care– Proper training
• Patient Recognition
• Coordination of Care
• Restraint Techniques
P t l– Proper protocols
– Proper online medical control
Excited DeliriumManagement
CNY EMS Regional ProtocolCNY EMS Regional Protocol– Required med control order for sedation
– Increased time from physical to chemical restraint
– Difficult communications with crew
– Two paramedics hurt in first 48 hours of our new Spike epidemic
4/29/2015
25
Excited DeliriumManagement
CNY EMS Regional ProtocolCNY EMS Regional Protocol– NYSOH BEMS granted CNYEMS
emergency protocol change
– Midazolam 10 mg IM or 5 mg IV as standing order.
Cl h i– Close chart review
Sudden In Custody Death
4/29/2015
26
4/29/2015
27
Sudden In Custody Death
Law Enforcement PerspectiveLaw Enforcement Perspective– Irrational and combative
persons
– Danger to self
– Danger to officers
– Danger to community
– Must be subdued
Sudden In Custody Death
Law Enforcement PerspectiveLaw Enforcement PerspectiveMeans of control
– Compliance by command– Compliance by pain
• Battons• Joint Lock Maneuvers• OC SprayOC Spray
– Compliance by Taser– Compliance by group force
4/29/2015
28
Sudden In-Custody Death
• Progression• Progression– Excited Delirium Symptoms
– Significant Restraint
– Acute Dyspnea
– Suddenly Quiet
– Death (bradyasystole)
Sudden In-Custody Death
• HypothesesHypotheses – Catacholamine Surge and Drop– Hypokalemia – Cardiovascular Disoder
• Genetic – Long QT Syndrome• Drug Abuse Induced Heart DamageDrug Abuse Induced Heart Damage
– Brain Biochemically Damaged– Uncompensated Acidosis
4/29/2015
29
Hypothesis: Uncompensated Acidosis
Sudden In-Custody Death
Hypothesis: Uncompensated Acidosis
• Metabolic acidosis
• Compensatory alkalosis…
Sudden In-Custody Death
Hypothesis: Uncompensated AcidosisHypothesis: Uncompensated Acidosis
• if ventilation compromised…
• Respiratory acidosis or
Uncompensated metabolic acidosis
• Cardiovascular Collapse• Cardiovascular Collapse
4/29/2015
30
Sudden In-Custody Death
• SICD Prevention• SICD Prevention– Minimize struggle
– Patient monitor
– Early Involvement of EMS
Sudden In-Custody Death
• SICD Prevention• SICD Prevention– Cardiac Monitoring
– Watch Respirations
– Expect Decompensation
– Rapid Transport
– Early, effective CPR
4/29/2015
31
Sudden In-Custody Death
October 2005October 2005
Donald Lewis found by the side of the road by Officer Raymond Shaw
Sudden In-Custody Death4:45
St tStart
4:45.40
Into Road
4:50.45
Restraint Starts
4/29/2015
32
4:49.30
O t f R dOut of Road
4:49.50
Less Restraint
Sudden In-Custody Death4:51.00
H Ti St tHog Tie Starts
Increasing Restraints
4:51.15
Movement to improve restraint
4:51.30
Breathing
4/29/2015
33
Sudden In-Custody Death4:51.40
N t B thiNot Breathing
4:51.58
Recognized Arrest
4:51.30
Pulse Check
Sudden In-Custody Death4:53.30
RRescue Breathing Started
4/29/2015
34
4:53.45No pulse?No pulse?
4:54.30CPR started5:2
4:55.10SROC
4:55.30Breath slower?Breath slower?
4:50.00+Pulse
Sudden In-Custody Death4:56.51
EMS iEMS arrives
4:59.30
CPR Started?
Quality?
5:00 Intubation
5:00.20 Ongoing Intubation
4/29/2015
35
Sudden In-Custody Death05:01
Still I t b tiStill Intubating
No CPR
5:01.22
Office Mental State
EMS Medicine LiveApril 2015
SummarySummary– Excited Delirium: Clinical Findings,
Etiologies, Management
– SICD: Progression, Hypotheses of Cause, T C P iTreatment, Case Presentation