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Symptoms Answer 'Crazy Person' or Excited Delirium

It’s likely that not a day goes by when an EMS provider isn’t summoned to provide care for a “crazy person” somewhere in the nation. And it could be that the patient is experiencing an episode of excited delirium.

Responders need to know the signs and symptoms of excited delirium, and Dr. Peter Antevy set about teaching these at Firehouse Expo. So committed to educating people about excited delirium, he has made his entire presentation available online at his website.

“If you have a crazy person running around naked in the street, you should be thinking about excited delirium, unless you’re at a carnival in Brazilor someplace,” said Antevy, who is a medical director for Davie (Fla.) Fire-Rescue Department.

Prior to today’s verbiage of excited delirium, it was historically known asBell’s Mania, named after the man who discovered it. Antevy said the death rate after becoming afflicted with Bell’s Mania was 75 percent and there were no medications to treat it. The death rate for excited delirium, which was officially recognized in 2009, is down to 8 to 14 percent.

The hallmarks of excited delirium include past or present psychological issues, past or present drug or alcohol use, incoherent thought processes and speech, and clothing off with a high body temperature, Antevy said.

Some exhibit attraction to bright shiny objects, hence the tendency to walk into traffic, Antevy said. He noted that all have resistance to pain, superhuman strength, will speak or yell incoherently, and won’t follow commands from anyone, including police.

Unfortunately, people with these symptoms have died in custody, yet when the autopsy reports are reviewed, everything with the individual appears normal, he said.

Antevy said he has a theory about excited delirium, that those who exhibit symptoms have excessive dopamine to the brain which works much the same way as cocaine or Ecstasy. He said that explains the agitation and the hyperthermia the patients exhibit. The condition is exacerbated when patients have other drugs on board, he added.

The proper response to excited delirium is a concerted effort with police and EMS providers, Antevy said, noting that it is a true medical emergency and not just a person high on drugs, resisting arrest.

Excited delirium, according to Antevy, can be brought on by essentially three triggers, including an overdose on stimulants or hallucinogenic drugs, drug withdrawal, or it could be a person with mental illness who has been off medication for a significant amount of time.

While the number of people with excited delirium who die in custody has diminished, there are many reasons why they do, Antevy said. One of the principal reason is they can’t breathe, he said. Because they are overheated, sometimes reaching temperatures up to 107 degrees, and they are no longer sweating because of dehydration and other conditions, the only way left for people to try to cool their bodies is to breath rapidly, tachypnea, which is almost like panting, he said.

When excited delirium patients are “hogtied” and restrained in a prone position, they can’t breathe as effectively as their bodies need, Antevy said. It is far better to sedate the patient with drugs, including any of the Benzodiazephine family, including valium, Versed and Ativan, or a new one that’s gaining popularity, ketamine. Haldon might also be used, but it has effects that will need close monitoring and might hinder the patient’s natural ability to compensate, Antevy said.

Antevy said police need to recognize excited delirium as a true medical emergency and get EMS involved quickly and work in concert with providers for the best outcomes.

Physical restraint, while it may seem necessary, can cause harm to the patients because in their state of agitation, any symptoms of excited delirium will be exacerbated, he said.

In addition to the agitation, they’ll exhibit hyperthermia, sweating and dehydration, which will lead to a death sequence if not reversed.

“Law enforcement officers need to know what is going on,” Antevy said. “These people will lack remorse, have no fear and no rational thoughts.” Trying to talk these patients down is really rather useless. They need to call EMS right away and not 25 to 30 minutes after the initial call.”

Instead of answering the agitation with force, such as hog ties and physical struggling, sedation is the answer when possible, Antevy said, noting that while many police officers might recognize the physiology of the emergency, they have to take the necessary steps to protect themselves and the public. That might include physical restraints and even use of a Taser on the patient/suspect.

“They want to get home to their families and I can understand that,” Antevy said. The more EMS and police work together, and are educated about the signs and symptoms, the more likely a patient will experience a good outcome, he said.

After the patient has been sedated, Antevy recommends IV saline and, if necessary bicarbonate to reduce the acidosis found in most excited delirium patients. If bicarbonate is administered, the provider must monitor the patient closely, paying particular attention to end tidal readings. Ice packs to cool the body are also highly recommended, he said.

And any time sedatives are administered, he said “good medic common sense” is needed to make sure the patient’s compensatory body functions are maintained.

It’s very likely that an excited delirium patient will be experiencing tachycardia as the body tries to react to the additional simulation and physiological reactions taking place. Rapid pulse rates are common in excited delirium patients.

Antevy said providers need to be watchful of excited delirium patients because they decompensate quickly, often going into bradycardia and even asystole without much warning. That’s why rapid transport is always indicated with patients suspected of having excited delirium, he said.

And the hospital should be alerted to suspected cases of excited delirium so they know what to expect. It’s not uncommon for people exhibiting symptoms to be sent off to the psychiatric ward for evaluation when they should be headed to the emergency room, or intensive care unit for treatment of life-threatening conditions.

Even basic life support providers can make a big difference in the outcome, Antevy said. By being an advocate for the patient, and not letting the hospital ship them to a psych ward, and making sure police officers have a good understanding what they are dealing with and perhaps suggesting better ways to restrain the patient which might allow them to breath more effectively.

Not all patients will survive this life-threatening condition and that’s why Antevy said it’s important to “document, document, document” all findings and observations with these patients.

“That way, when you come under scrutiny, and you will, you’ll have the documentation to indicate what was going on,” Antevy said. High temperature, with a number, is a good thing to have, along with heart rate and state of agitation, which will all be clues and evidence to help defend one’s self from any accusations of wrongdoing.

“It’s important to recognize excited delirium so that it can be dealt with safely and efficiently,” Antevy said.