Author: Chris Odedun / Codes: CAP4 / Published: 24/04/2018
Stories can help us understand patients, ourselves and colleagues better, and so be better emergency physicians. What are your learning points from the narrative below? Get in touch and tell us on Twitter, or via email to firstname.lastname@example.org. All staff and patient mentions have been anonymised for this blog post.
“Can you come outside please, Doc? The Police want to talk to you about a patient”
The relative tranquillity of the night shift thus was about to be broken. I swallowed my apprehension and walked outside.
Facing the ED entrance was a backed-up police van, rear doors open, cage closed. Seven police officers clustered around it as I approached…
You effing b*rd. You effing b*rd.
You effing b*rd. Eff off you gay.
I introduced myself to the gaggle of officers.
I eyed the man behind the cage door.
Topless. Perhaps 40. Shaved head. Sweaty. Much less green than the Incredible Hulk and more verbose, but not much word variation…and just as inappropriately angry.
“So we picked this guy up from outside a club. He was swearing at the security like a trooper.”
Nothing’s changed, then.
“The doorman was about to lamp him but didn’t. We called his girlfriend – she was saying they snorted some coke together and half an hour later he was like this. He tore up their lounge and ran off. Hes been chatting nonsense. Can we bring him in, doc?”
Under no circumstances. “Er hold on a sec. Need to think about this a bit. Can you give me a couple of minutes?”
I dispatched a colleague with his details to talk to the mental health liaison team while I called the on-call consultant.
I ran the presentation past her. “So it sounds like it’s all drug-related. Hes still in the cage. I can’t see any injuries to his scalp. Im gonna have to sedate him for a CT scan, aren’t I?”
She replied: “I’d give him some ketamine. Get the police to help you. Get stuff ready in resus to assess him in there after you sedate him. Watch out for how they hold him down, were worried about excited delirium – if he can’t blow off his CO2, he’ll arrest, pronto. Be ready to tube if you need to get control.”
Ok. The start of a plan.
Excited delirium. Ive read about this! Isnt that the awful coming together of sympathetic overdrive and dopaminergic disaster? Something about agitation, maniacal strength, hyperthermia… Lactate of 15 and all that. High risk of death…
News back from indoors – not known to mental health services.
“Can you guys drive the van around to the ambulance doors so were closer to resus?”
Give him an intramuscular dose. Something thatll keep his airway patent. Do it outside, police holding him down so no-one gets a needlestick. Bring a trolley outside. Best way to keep the rest of the department calm and avoid making a scene. Get him straight onto it when hes not resisting. Take him straight in and carry on. Treat in his best interests, Theres no way he has capacity. Get the collateral story later.
I went inside to prepare things in resus. We drew up some ketamine, cleared a bay and took the trolley outside, informing the nurse in charge. I bleeped the ITU registrar.
“What, you want me to come now?” Yes I want you to come now, so we can pre-brief, you know, plan.
Oxygen, ready, airway adjuncts, ready. Cannulation paraphernalia, ready. Rest of the department delegated.
I go back outside. I feel like I have akathisia: broody restlessness, a smooth paste of get-on-with-it mixed with wait-a-minute-lets-run-through-the-mental-checklist-again.
Who the eff are you?
We line up the trolley in the ambulance bay, next to the doors. I instruct the police officers. I want them to be gentle. Ive seen those I cant breathe videos. I need access to his shoulder. The syringe of white ketamine in my right hand. What if I give an officer a needlestick?
“Ok team. one, two, three..”
They pull him out.
“What are you doing? What are you doing you bastard?”
They push him to the floor. Bizarrely hes not struggling, though a barrage of words are streaming from his mouth. In maybe 3 seconds, I unsheathe the needle, pinch his deltoid, inject, pull the needle out, and hold it up in the air like some empty trophy visible to everyone.
We wait. 10 seconds. His breathing calms. No more effing and blinding. 20 seconds. Now we can work on treating him. “On the trolley. One, two, three..”
In we go to resus.
Narrative-based learning is a new style for RCEMLearning, and we’d be interested to know what you think please let us know. We’re hoping it will encourage mental rehearsal of situations for you, as well as highlighting some key points. Now you’ve read this blog, we’re sure you’ll be able to manage your next case of potential excited delirium.
Excited Delirium: the presentation of features of “acute delirium” and hyper-adrenergic autonomic dysfunction.
It’s the extreme end of an agitated patient. You’ve all seen them, they’re difficult to manage, often assault many staff members, and exhaust security.
Management of ABD: safe sedation is important, as this turns off the adrenergic surge that is creating so many of the problems. In other countries where ABD is more common, they have well oiled and practiced sedation teams; a key part of this is one person puts oxygen on. This corrects a potentially reversible cause of agitation (hypoxia) as well as reducing any spit contamination. There is a really significant potential for a needlestick injury. Ketamine is a good choice for sedative agent, because it should maintain his airway, and respiratory drive (what happens to all that lactate if you can’t compensate?). The RCEM guidance runs through many different therapeutic options, but the one that interests me most is intranasal midazolam because it only takes 3-5 minutes to work, and doesn’t need any needles. The IM lorazepam more of us are comfortable with using takes 15-30 minutes to work, and needles are involved.
Afterwards: once you’ve sedated the patient, then you need to remember to diagnose them. Yes, they may be suffering from drug induced acute behavioural disturbance, or they may have sepsis, or serotonin syndrome, or a cerebral event. If you don’t look for it, you won’t find it.
Psychiatric Emergencies In The Adult Patient (RCEMLearning)
Guidelines for the management of excited delirium/acute behavioural disturbance (RCEM Best Practice guideline)
Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum