Excited Delirium Syndrome Lacks Research, Coding

PHILADELPHIA – High doses of the anesthetic ketamine hydrochloride injected into the anterior thigh are the first line of defense when treating a patient with excited delirium syndrome, Dr. James R. Roberts reported at the meeting.

Excited delirium syndrome (ExDS) is characterized by delirium, agitation, acidosis, and hyper adrenergic autonomic dysfunction, according to the Journal of Emergency Medicine (J. Emerg. Med. 2011 March 24 [doi: 10.1016/j.jemermed.2011.02.017]). It is often comorbid with serious mental illness, drug abuse, or a combination of the two, said Dr. Roberts, who serves as director of emergency medicine at Mercy Philadelphia Hospital and Mercy Fitzgerald Hospital, and has more than 40 years of experience working in emergency departments.

Dr. Roberts said ExDS patients often have symptoms that include severe hypothermia, high levels of testosterone, elevated temperature, extreme paranoia, and tolerance to pain, and sweating. These patients also often display super-human strength and are non-compliant with police. Some ExDS patients have an attraction to glass or mirrors. After an episode, patients also tend to have no memory of the event.

According to the American College of Emergency Physicians (ACEP), which published a white paper on ExDS and formally recognized the illness as a unique syndrome in 2009, more than 95% of published fatal cases of ExDS involve males with a mean age of 36. After the cohort of people who abuse stimulants, those with psychiatric illness make up the second-largest and "distinctly smaller cohort of ExDS cases and deaths," according to the white paper.

Death from ExDS is often sudden and can result from several conditions, including cardiac arrest, renal failure, or hypothermia. The mortality is nearly 75%, yet ExDS is neither well recognized nor understood within the medical community, Dr. Roberts said. He also noted an absence of coding that can be used to classify the syndrome.

Diagnosis and research of ExDS is tricky, the report noted, because of a lack of well-defined and consistent case definitions, as well as shared characteristics with other diseases. For example, ExDS can be confused with heat stroke, alcohol withdrawal, and post-seizures.

To help decrease mortality and complications, Dr. Roberts encouraged physicians and law enforcement to raise their awareness of the condition.

"In the heat of the battle [between the patient and law enforcement], the patient stops struggling. The [police are] happy, but what really happens is the patient is dying and they’re not aware of it," Dr. Roberts said.

He added that police often mistake ExDS for another psychiatric disease, such as schizophrenia, and they often feel compelled to use physical force to encourage compliance. Tasers, he added, should only be used to remove any weapons the patient might have. Tasers increase the patient’s physiological stress and increase likelihood of death, he said.

Medical treatment should be used as soon as possible to improve outcomes.

"The cooler heads have to prevail," Dr. Roberts said. "Doctors have to set the example."

PHILADELPHIA – High doses of the anesthetic ketamine hydrochloride injected into the anterior thigh are the first line of defense when treating a patient with excited delirium syndrome, Dr. James R. Roberts reported at the meeting.

Excited delirium syndrome (ExDS) is characterized by delirium, agitation, acidosis, and hyper adrenergic autonomic dysfunction, according to the Journal of Emergency Medicine (J. Emerg. Med. 2011 March 24 [doi: 10.1016/j.jemermed.2011.02.017]). It is often comorbid with serious mental illness, drug abuse, or a combination of the two, said Dr. Roberts, who serves as director of emergency medicine at Mercy Philadelphia Hospital and Mercy Fitzgerald Hospital, and has more than 40 years of experience working in emergency departments.

Dr. Roberts said ExDS patients often have symptoms that include severe hypothermia, high levels of testosterone, elevated temperature, extreme paranoia, and tolerance to pain, and sweating. These patients also often display super-human strength and are non-compliant with police. Some ExDS patients have an attraction to glass or mirrors. After an episode, patients also tend to have no memory of the event.

According to the American College of Emergency Physicians (ACEP), which published a white paper on ExDS and formally recognized the illness as a unique syndrome in 2009, more than 95% of published fatal cases of ExDS involve males with a mean age of 36. After the cohort of people who abuse stimulants, those with psychiatric illness make up the second-largest and "distinctly smaller cohort of ExDS cases and deaths," according to the white paper.

Death from ExDS is often sudden and can result from several conditions, including cardiac arrest, renal failure, or hypothermia. The mortality is nearly 75%, yet ExDS is neither well recognized nor understood within the medical community, Dr. Roberts said. He also noted an absence of coding that can be used to classify the syndrome.

Diagnosis and research of ExDS is tricky, the report noted, because of a lack of well-defined and consistent case definitions, as well as shared characteristics with other diseases. For example, ExDS can be confused with heat stroke, alcohol withdrawal, and post-seizures.

To help decrease mortality and complications, Dr. Roberts encouraged physicians and law enforcement to raise their awareness of the condition.

"In the heat of the battle [between the patient and law enforcement], the patient stops struggling. The [police are] happy, but what really happens is the patient is dying and they’re not aware of it," Dr. Roberts said.

He added that police often mistake ExDS for another psychiatric disease, such as schizophrenia, and they often feel compelled to use physical force to encourage compliance. Tasers, he added, should only be used to remove any weapons the patient might have. Tasers increase the patient’s physiological stress and increase likelihood of death, he said.

Medical treatment should be used as soon as possible to improve outcomes.

"The cooler heads have to prevail," Dr. Roberts said. "Doctors have to set the example."

PHILADELPHIA – High doses of the anesthetic ketamine hydrochloride injected into the anterior thigh are the first line of defense when treating a patient with excited delirium syndrome, Dr. James R. Roberts reported at the meeting.

Excited delirium syndrome (ExDS) is characterized by delirium, agitation, acidosis, and hyper adrenergic autonomic dysfunction, according to the Journal of Emergency Medicine (J. Emerg. Med. 2011 March 24 [doi: 10.1016/j.jemermed.2011.02.017]). It is often comorbid with serious mental illness, drug abuse, or a combination of the two, said Dr. Roberts, who serves as director of emergency medicine at Mercy Philadelphia Hospital and Mercy Fitzgerald Hospital, and has more than 40 years of experience working in emergency departments.

Dr. Roberts said ExDS patients often have symptoms that include severe hypothermia, high levels of testosterone, elevated temperature, extreme paranoia, and tolerance to pain, and sweating. These patients also often display super-human strength and are non-compliant with police. Some ExDS patients have an attraction to glass or mirrors. After an episode, patients also tend to have no memory of the event.

According to the American College of Emergency Physicians (ACEP), which published a white paper on ExDS and formally recognized the illness as a unique syndrome in 2009, more than 95% of published fatal cases of ExDS involve males with a mean age of 36. After the cohort of people who abuse stimulants, those with psychiatric illness make up the second-largest and "distinctly smaller cohort of ExDS cases and deaths," according to the white paper.

Death from ExDS is often sudden and can result from several conditions, including cardiac arrest, renal failure, or hypothermia. The mortality is nearly 75%, yet ExDS is neither well recognized nor understood within the medical community, Dr. Roberts said. He also noted an absence of coding that can be used to classify the syndrome.

Diagnosis and research of ExDS is tricky, the report noted, because of a lack of well-defined and consistent case definitions, as well as shared characteristics with other diseases. For example, ExDS can be confused with heat stroke, alcohol withdrawal, and post-seizures.

To help decrease mortality and complications, Dr. Roberts encouraged physicians and law enforcement to raise their awareness of the condition.

"In the heat of the battle [between the patient and law enforcement], the patient stops struggling. The [police are] happy, but what really happens is the patient is dying and they’re not aware of it," Dr. Roberts said.

He added that police often mistake ExDS for another psychiatric disease, such as schizophrenia, and they often feel compelled to use physical force to encourage compliance. Tasers, he added, should only be used to remove any weapons the patient might have. Tasers increase the patient’s physiological stress and increase likelihood of death, he said.

Medical treatment should be used as soon as possible to improve outcomes.

"The cooler heads have to prevail," Dr. Roberts said. "Doctors have to set the example."