New Study: Fast, Effective EMS Option For Excited Delirium Cases

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Preliminary results from a new, ongoing study tend to support a growing trend in the management of dangerous subjects in the throes of Excited Delirium Syndrome (ExDS).

The findings should be part of the dialog if you are working on a joint law enforcement/EMS protocol for addressing this perplexing problem, as recommended in Force Science News (4/9/12).

The study, being conducted by Dr. Michael Curtis, former EMS medical director for Portage County, WI, is documenting cases among seven Wisconsin ambulance services whose paramedics have administered the drug ketamine, a potent sedative, to physically violent individuals before transporting them to a hospital. Curtis, an ER physician in Stevens Point, WI, says more than 50 cases involving agitated and combative behavior have been noted so far. Roughly 80% met the descriptors for ExDS, he estimates.

Given in the proper dosage, ketamine has proven to be “extremely effective” in sedating almost all of these subjects into a calm, controllable state within three to five minutes, Curtis told FSN, adding that “all survived with no unexpected adverse side effects.” The sedation typically sustained for 20-30 minutes –long enough for the subjects to reach a medical facility where treatment to reduce their symptoms could be pursued.

Many experts believe that rapid calming reduces the extreme physiological stress caused by an extended struggle with police and continued agitation after restraint that contribute to the risk of death in ExDS events. “Moreover, before emergency medical professionals can deliver a lifesaving treatment, they have to initiate an IV, which is often impossible until the patient is made calm,” Curtis says.

Traditionally, ketamine has been used as an anesthetic or analgesic (pain reliever), Curtis explains. But of late, an increasing number of EMS units in the US have begun injecting it in ExDS subjects and other violent parties, once police have established sufficient restraint to allow it. The ideal dosage, Curtis says, appears to be 5 mg per kg of a subject’s weight (450 mg for a 200 lb. subject, for example). More can be administered if necessary without dire consequences, he says.

In a recently published paper, a team led by Dr. Jeffrey Ho, a prominent researcher of in-custody deaths, reports on two cases in which ketamine was used successfully as part of an ExDS response.

In one case, police were called to handle a 35-year-old chronic cokehead, partially nude in 11-degree weather, who was acting bizarrely and trying to enter a closed business. The cops found him raving nonsensically, “remarkably strong,” and unresponsive to manual pain-compliance. Even though eight officers eventually proned him out, he continued to bang his head on the pavement until an EMS responder delivered a 500-mg intramuscular injection of ketamine through his clothing and into his butt. Within four minutes, he was calm. He arrived alive at a hospital and there was “returned to normal” with no negative after-effects.

In the second case, police responded to a domestic and confronted a highly agitated, partly nude 40-year-old B/M with a history of schizophrenia and substance abuse. He was screaming requests to speak with God and engaged officers in “a significant fight” before he was Tasered into submission. The police had wisely summoned EMS early in the call, and once the subject was down a medic injected ketamine. This subject was calm in about three minutes–“overall success with no complications,” Ho writes. (An abstract of this study can be accessed at: http://www.ncbi.nlm.nih.gov/pubmed/23231451)

“Law enforcement and EMS need to work together to handle excited delirium cases,” Curtis says. “Neither can do it alone. Police need to realize they are dealing with a medical/psychiatric emergency, and EMS needs to be prepared to move in quickly and get the subject sedated immediately and transported by ambulance to the ER. For best results, there has to be a community-wide protocol, involving agencies that are not always accustomed to working together.”

Curtis presented a preliminary report on the Wisconsin experience and a review of professional literature related to ketamine and ExDS at the latest annual conference of the Institute for the Prevention of In-Custody Deaths.

[Contact information: Dr. Curtis, Michael.Curtis@ministryhealth.org; Dr. Ho, jeffrey.ho@hcmed.org. Our thanks to attorney Michael Brave, president of LAAW International, for alerting us to these studies.]

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