Prehospital Ketamine Administration for Excited Delirium with Illicit Substance Co-Ingestion and Subsequent Intubation in the Emergency Department

Introduction: Excited delirium, which has been defined as combativeness, agitation, and altered sensorium, requires immediate treatment in prehospital or emergency department (ED) settings for the safety of both patients and caregivers. Prehospital ketamine use is prevalent, although the evidence on safety and efficacy is limited. Many patients with excited delirium are intoxicated with illicit substances. This investigation explores whether patients treated with prehospital ketamine for excited delirium with concomitant substance intoxication have higher rates of subsequent intubation in the ED compared to those without confirmed substance usage. Methods: Over 28 months at two large community hospitals, all medical records were retrospectively searched for all patients age 18 years or greater with prehospital ketamine intramuscular (IM) administration for excited delirium and identified illicit and prescription substance co-ingestions. Trained abstractors collected demographic characteristics, history of present illness (HPI), urine drug screens (UDS), alcohol levels, and noted additional sedative administrations. Substance intoxication was determined by UDS and alcohol positivity or negativity, as well as physician HPI. Patients without toxicological testing or documentation of substance intoxication, or who may have tested positive due to ED sedation, were excluded from relevant analyses. Subsequent ED intubation was the primary pre-specified outcome. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare variables. Results: Among 86 patients given prehospital ketamine IM for excited delirium, baseline characteristics including age, ketamine dose, and body mass index were similar between those who did or did not undergo intubation. Men had higher intubation rates. Patients testing positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates, and synthetic cathinones, both bath salts and flakka, had similar rates of intubation compared to those negative for these substances. Of 27 patients with excited delirium and concomitant cocaine intoxication, nine (33%) were intubated compared with four of 50 (8%) without cocaine intoxication, yielding a 5.75 OR (95%, CI 1.57 to 21.05; P = .009). Conclusion: Patients treated with ketamine IM for excited delirium with concomitant cocaine intoxication had a statistically significant 5.75-fold increased rate of subsequent intubation in the ED. Amongst other substances, no other trends with intubation were noted, but further study is warranted.

Medicolegal evaluation of pontine hemorrhage at autopsy- Highlights from a case and an overview

One in ten non-traumatic intracerebral hemorrhages (ICH) is located in the pons with chronic arterial hypertension as the leading etiology. In the forensic context, deaths related to a pontine hemorrhage (PH) are usually encountered in situations of drug abuse, excited delirium, trauma, as well as in sudden natural deaths where some hypertensive catastrophe is the usual underlying mechanism. The clinical presentation of PH may be variable, causing a failure in timely diagnosis that, if presents with unexplainable circumstances, may become the subject of medicolegal concern. The present case relates to a middle-aged man with a long history of hypertension and presents during an afternoon with an abrupt onset of deleterious symptoms. The patient was managed conservatively but succumbed to his illness and expires during treatment. A questionable diagnosis and the case circumstances, however, directed the doctors to inform the police. A medicolegal autopsy was therefore carried out that leads to the discovery of a lethal pontine hemorrhage rupturing into the fourth ventricle and involving the adjacent cerebellar tissues as well. Severe atherosclerosis of the basal arteries constituting Circle of Willis and Vertebrobasilar system was seen along with their hallmark effects that became evident during brain sectioning. Pathological stigmata of well established hypertension were found in the heart and kidneys. A clinic pathological correlation of the physical characteristics and topography of the hematoma to its severity was also carried out, based upon the known CT and autopsy findings. The possibility of a drug related or traumatic and secondary brainstem/Duret hemorrhage was ruled out.

A retrospective study on the safety and effectiveness of olanzapine versus midazolam for pre-hospital management of excited delirium syndrome

Objective: To evaluate the safety and effectiveness of olanzapine compared to midazolam for the pre-hospital management of excited delirium syndrome. Methods: A retrospective review of patients who were treated by ambulance crew for excited delirium syndrome from 2016 to 2019 was performed. The drug of choice was given per Fire Service Department’s paramedic protocol (intramuscular midazolam January 2016 to October 2018 and intramuscular olanzapine October 2018 to December 2019). The primary outcome was the proportion of patients experienced at least one adverse event. The secondary outcome was the successful sedation rate. Results: A total of 201 patients were included in the study. Ninety-nine patients had pre-hospital midazolam and 102 received olanzapine. Thirty-one patients experienced adverse event after arrival to A&E, including a drop of Glasgow Coma Scale score to below 8 (90%), hypotension (6%), and airway obstruction (3%): 17 (17% patients; 1 airway obstruction and 16 Glasgow Coma Scale score below 8) in midazolam group and 14 (14% patients; 2 hypotension and 12 Glasgow Coma Scale score below 8) in olanzapine group (p = 0.41). Sixty-eight patients (69%) in midazolam group achieved successful sedation, compared with 79 (77%) in olanzapine group (p = 0.20). More adverse events were seen with midazolam than olanzapine in alcohol intoxication subgroup with statistical significance (12 vs 2, p = 0.03). Conclusion: Both midazolam and olanzapine can achieve a satisfactory success rate of sedation. More adverse events are associated with midazolam use in patients with acute alcohol intoxication, especially over-sedation and airway compromise. Olanzapine would be a safer choice in the pre-hospital setting where the resource is limited, and differentiation of underlying causes is not always possible.

Sudden cardiac death in excited delirium, and how to prevent it

The purpose of this study was to review data on restraint related deaths in persons in a state of excited delirium (ExDS) and to propose guidelines for treatment. We analysed three unexpected deaths in persons in a state of ExDS shortly after police restraint. Death which occurs during a police intervention, using physical restraints, may be related to placing the individual in a prone position, the use of neck holds, expert grips, and handcuffs or pepper spray. ExDS results in an altered mental state with agitation, aggression, paranoia, and panic attacks, and is a life-threatening condition. Therefore, before police intervention is initiated, a medical emergency team should be present. In patients with ExDS, physical restraints used by the police should be brief, effective, and include rapid tranquilization (sedation) using benzodiazepines, and antipsychotics.