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Springer B. Hyperactive Delirium with Severe Agitation. Emerg Med Clin North Am 2024; 42:41-52. [PMID: 37977752 DOI: 10.1016/j.emc.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying pathophysiology is variable and often results from sympathomimetic abuse, psychiatric disease, sedative-hypnotic withdrawal, and metabolic derangement. Patients can go from a combative state to periarrest with little warning. Safety of the patient and of the medical providers is paramount and the emergency department should be prepared to manage these patients with adequate staffing, restraints, and pharmacologic sedatives. Treatment with benzodiazepines, antipsychotics, or ketamine is recommended, followed by airway protection, supportive measures, and cooling of hyperthermia.
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Affiliation(s)
- Brian Springer
- Division of Tactical Emergency Medicine, Department of Emergency Medicine, Wright State University, 2555 University Boulevard, Suite 110, Fairborn, OH 45324, USA.
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Slocum S, Fiorillo M, Harding E, Owen J, Long R, Dunn T, Martin I. In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review. Forensic Sci Med Pathol 2023; 19:573-594. [PMID: 36350497 DOI: 10.1007/s12024-022-00548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration. To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement. In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself. After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.
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Affiliation(s)
- Sarah Slocum
- Department of Psychiatry, Geisel School of Medicine, Lebanon, NH, USA.
- New Hampshire Hospital, 36 Clinton St, Concord, NH, 03301, USA.
| | - Matthew Fiorillo
- Department of Psychiatry and Behavioral Health, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eric Harding
- Medical College of Wisconsin Libraries, Milwaukee, WI, USA
| | - Julie Owen
- Department of Psychiatry and Behavioral Medicine, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ruby Long
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thom Dunn
- Psychological Sciences, University of Northern Colorado and Behavioral Health Service, Denver Health Medical Center, Denver, CO, USA
| | - Ian Martin
- Department of Emergency Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Strömmer EMF, Leith W, Zeegers MP, Freeman MD. The role of restraint in fatal excited delirium: a research synthesis and pooled analysis. Forensic Sci Med Pathol 2020; 16:680-692. [PMID: 32827300 PMCID: PMC7669776 DOI: 10.1007/s12024-020-00291-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 02/02/2023]
Abstract
The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.
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Affiliation(s)
- Ellen M F Strömmer
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands.
| | - Wendy Leith
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Maurice P Zeegers
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Michael D Freeman
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
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Stevenson R, Tracy DK. Acute behavioural disturbance: a physical emergency psychiatrists need to understand. BJPSYCH ADVANCES 2020. [DOI: 10.1192/bja.2020.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYThe phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an underrecognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. Causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.
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Three postmortem case reports of the excited delirium syndrome – A short comparison. J Forensic Leg Med 2019; 66:134-137. [DOI: 10.1016/j.jflm.2019.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/21/2022]
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Dawes D, Ho J. Commentary on: Gibbons J, Mojica A, Peele M. Human electrical muscular incapacitation and effects on QTc interval. J Forensic Sci https://doi.org/10.1111/1556-4029.13490. Epub 2017 April 17. J Forensic Sci 2017; 62:1418-1419. [DOI: 10.1111/1556-4029.13595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Donald Dawes
- Emergency Department; Lompoc Valley Medical Center; 1515 E Ocean Ave Lompoc CA 93436
| | - Jeffrey Ho
- Emergency Department; Hennepin County Medical Center; 701 Park Avenue South Minneapolis MN 55415
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Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System. Prehosp Disaster Med 2016; 31:563-9. [PMID: 27517801 DOI: 10.1017/s1049023x16000662] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Excited delirium syndrome (ExDS) is defined by marked agitation and confusion with sympathomimetic surge and incessant physical struggle, despite futility, which may lead to profound pathophysiologic changes and sudden death. Severe metabolic derangements, including lactic acidosis, rhabdomyolysis, and hyperthermia, occur. The pathophysiology of excited delirium is a subject of ongoing basic science and clinical research. Positive associations with ExDS include male gender, mental health disorders, and substance abuse (especially sympathomimetics). Excited delirium syndrome patients often exhibit violent, psychotic behavior and have "superhuman" strength which can result in the patient fighting with police and first responders. Continued struggle can cause a patient with ExDS to experience elevated temperature (T) and acidosis which causes enzymes to fail, leading to sudden death from cardiovascular collapse and multi-system organ failure. Therefore, effective early sedation is optimal to stop this fulminant process. Treatment of ExDS must be focused on rapidly, safely, and effectively sedating the patient and providing intensive, supportive care. Benzodiazepines, like midazolam, may not be ideal to sedate ExDS patients since their onset takes several minutes, and their side effects include loss of airway control and respiratory depression. Injectable antipsychotic medications have a relatively slow onset and may cause prolongation of the QTc interval. Ketamine is the ideal medication to sedate patients with ExDS. Ketamine has a rapid, predictable onset within three to four minutes when given by intramuscular (IM) injection. It does not adversely affect airway control, breathing, heart rate, or blood pressure (BP). In this retrospective case series, prehospital scenarios in which ExDS patients received ketamine by paramedics for sedation, and their subsequent treatment in the emergency department (ED) and hospital, are described. It is demonstrated that ketamine administered by paramedics in the prehospital setting of a community hospital based Emergency Medical Services (EMS) system is a safe and effective treatment for ExDS. Scaggs TR , Glass DM , Hutchcraft MG , Weir WB . Prehospital ketamine is a safe and effective treatment for excited delirium in a community hospital based EMS system. Prehosp Disaster Med. 2016;31(5):563-569.
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Jauchem JR. TASER® conducted electrical weapons: misconceptions in the scientific/medical and other literature. Forensic Sci Med Pathol 2014; 11:53-64. [DOI: 10.1007/s12024-014-9640-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2014] [Indexed: 11/27/2022]
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O'Brien AJ, Thom K. Police use of TASER devices in mental health emergencies: a review. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2014; 37:420-426. [PMID: 24656744 DOI: 10.1016/j.ijlp.2014.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The proliferation of TASER devices among police forces internationally has been accompanied by concerns about injuries and health effects, and about the use of TASER devices on vulnerable populations such as people with mental illness. TASER devices have generated a flood of research studies, although there remain unanswered questions about some of the key issues. This paper outlines the introduction of TASER devices to policing and their subsequent widespread adoption. The paper considers the role of police in mental health emergencies with a particular focus on use of TASER devices. Some factors contribute to the special vulnerability of people with mental illness to the effects of TASER devices. The paper also reviews research into use of TASER devices and raises issues about conflict of interest in research into TASER devices. We conclude that TASER devices look set to play a significant role in policing in the future. We make suggestions for a future research programme, and suggest guidelines for publication of papers in which there may be a conflict of interest.
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Affiliation(s)
- Anthony J O'Brien
- Centre for Mental Health Research, University of Auckland, Private Bag 92019, Auckland, New Zealand.
| | - Katey Thom
- Centre for Mental Health Research, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
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