Excited Delirium ================ þ AKA Agitated States, Agitated Delirium, Fatal Excited Delirium þ James Roberts take on rapid tranquilization, EM-News.com, 11/07 þ Differential: - Hypoxia or shock - Heatstroke - Sepsis - Meningitis - Brain Tumor or Abscess - DTs - psychiatric (e.g., hysteria) - rabies - tetanus - Centruroides scorpion bites - cocaine etc. OD - Serotonin Syndrome - Neuroleptic Malignant Syndrome - Status Epilepticus - quinolone antibiotic toxicity þ These days, highly associated with cocaine use - Associated with chronic cocaine use, not just OD - Combination of agitation, delirium, aberrant thermal regulation, rhabdo, sudden death. - Classic: bizarre and violent behavior: aggressive, combative, hyperactive, paranoid, strong, incoherent - Blood cocaine levels not all that high - "Intrasynaptic dopamine alteration": chronic cocaine use suspected to cause underlying problem of brainstem D-1 dopamine receptor downregulation (increased intrasynaptic dopamine) - Hyperthermia is bad prognostic sign: similar to neuroleptic malignant syndrome - Hypotension is very bad prognostic sign - Tend to go into PEA - Tend to have chronic cardiac damage from the cocaine abuse: + long-term elevations of epi and norepi cause myocyte calcium overload and cell destruction + characteristic contraction bands and microfocal cardiac necrosis like seen in pheo patients - May get renal failure and then DIC - Rx: + Benzos; ? periactin down NG + IV fluids + labs including ABG + Foley, check for myoglobin, monitor urine output + Consider IV hydration with bicarb to alkalinize the urine [get Ruttenber 1997 and Roth 1988 from Roberts EMN Oct 2007] The syndrome is characterised by sudden death and has a high mortality. Mann SC, Caroff CN, Bleier HR, Weiz WKR Lethal catatonia. Am J Psychiatry 1986;143:1374-81. A good review of the psychiatric disorders that can present with this and some of the complications has been discussed recently, although no cause for the sudden death has been established. Farnham FR, Kennedy HG. Acute excited states and sudden death. BMJ 1997;315:1107-8. It is rare that blood gas analysis is performed on patients in acutely excited states. These persons are often resisting Police arrest and there have been several highly-publicised cases of death while resisting arrest leading to allegations of Police brutality. Some of these patients are given large doses of major tranquillisers on admission to mental facilities or secure Hospitals and then die, leading to criticism of this management strategy. Sheppard D. Learning the lessons: mental health enquiry reports published in England and Wales between 1969-1994 and their recommendations for improving practice. London: Zito Trust, 1994. [below is related to a patient who seized and had near-drowning with aspiration and hypoxia] Initially, our first blood gas analysis (drawn for the forearm) was written off as having been contaminated with venous blood. This may explain the high pCO2 and low pO2 but does not explain the acidosis, which was profound (7.17). I therefore come to the conclusion that this result was genuine. This observation opens the door to a whole new understanding of these hyperexcitable states. In this patient, it was caused by cerebral hypoxia. However, the cause may be organic or psychiatric - the outcome is the same. I postulate that the extreme physical activity depletes the blood of oxygen and raises the carbon dioxide - effectively the patient is indulging in prolonged anaerobic exercise. As it happens rapidly, the heart muscle becomes acutely hypoxic and the heart presumably either stops abruptly or degenerates into VF. This also explains the acidosis, which was almost exclusively lactic acid. This phenomenon may also explain sudden death in athletes who then are found to have no detectable abnormality on post-mortem. Management is therefore to provide oxygen and to abolish the inappropriate muscular activity. Airway control by ET intubation and the accompanying paralysis will abort the muscle activity. Why then does tonic-clonic seizure activity not also lead to sudden death? Well, in the community it can do if unchecked. Most seizures are self-limiting, but status is dangerous. The muscle activity is usually less in seizures than in hyperexcitable states as well. So I end this little paper (which I am publishing formally) with a request. If any of the group get a patient with such a state please measure the gases before (or maybe immediately after) intubation to see if this is reproducible - a case report is less useful than a series! Best wishes, Rowley Cottingham rowley@cix.co.uk