Excited Delirium

Excited DeliriumThe dangers of synthetic drugs today

Bath SaltsThe synthetic cathinone products marketed as bath salts to evade detection by authorities should not be confused with products such as Epsom salts that are sold to improve the experience of bathing. Bath salts typically take the form of a white or brown crystalline powder and are sold in small plastic or foil packages labeled not for human consumption. Sometimes also marketed as plant food or, more recently, as jewelry cleaner or phone screen cleaner they are sold online and in drug paraphernalia stores under a variety of brand names, such as Ivory Wave," "Bloom," "Cloud Nine," "Lunar Wave," "Vanilla Sky," "White Lightning," and Scarface.

How Are Bath Salts Abused?

Bath Salts are typically taken orally, inhaled, or injected, with the worst outcomes being associated with snorting or needle injection.

The Chemical ReactionThe energizing and often agitating effects reported in people who have taken bath salts are consistent with other drugs like amphetamines and cocaine that raise the level of the neurotransmitter dopamine in brain circuits regulating reward-motivated behavior and movement. A surge in dopamine in these circuits causes feelings of euphoria and increased activity. A similar surge of the transmitter norepinephrine can raise heart rate and blood pressure.The hallucinatory effects often reported in users of bath salts are consistent with other drugs such as MDMA or LSD that raise levels of another neurotransmitter, serotonin.

Your Bodys Response to Bath SaltsCommon reactions from Bath Salts include cardiac symptoms (such as racing heart, high blood pressure, and chest pains) and psychiatric symptoms including paranoia, hallucinations, and panic attacks.Patients with the syndrome known as excited delirium from taking bath salts also may have dehydration, breakdown of skeletal muscle tissue, and kidney failure

Man on left was on bath salts, man on right was his victim

The result of his assault while on Bath Salts

Songs that reference MOLLY!PUSH PLAY

MOLLYMDMA (3,4-methylenedioxy-methamphetamine), popularly known as ecstasy or, more recently, as Molly, is a synthetic, psychoactive drug that has similarities to both the stimulant amphetamine and the hallucinogen mescaline. It produces feelings of increased energy, euphoria, emotional warmth and empathy toward others, and distortions in sensory and time perception.

How is Molly AbusedMDMA is taken orally, usually as a capsule or tablet. The popular term Molly (slang for molecular) refers to the pure crystalline powder form of MDMA, usually sold in capsules. The drugs effects last approximately 3 to 6 hours, although it is not uncommon for users to take a second dose of the drug as the effects of the first dose begin to fade. It is commonly taken in combination with other drugs.

The Chemical ReactionMDMA acts by increasing the activity of three neurotransmitters, serotonin, dopamine, and norepinephrine. The emotional and pro-social effects of MDMA are likely caused directly or indirectly by the release of large amounts of serotonin, which influences mood (as well as other functions such as appetite and sleep). Serotonin also triggers the release of the hormones oxytocin and vasopressin, which play important roles in love, trust, sexual arousal, and other social experiences.

Your Bodys Response to MollyThe surge of serotonin caused by taking MDMA depletes the brain of this important chemical, however, causing negative after effectsincluding confusion, depression, sleep problems, drug craving, and anxietythat may occur soon after taking the drug or during the days or even weeks thereafter.MDMA can have many of the same physical effects as other stimulants like cocaine and amphetamines. These include increases in heart rate and blood pressure, which are particularly risky for people with circulatory problems or heart disease. MDMA users may experience other symptoms such as muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills or sweating.In high doses, MDMA can interfere with the bodys ability to regulate temperature. This can lead to a sharp increase in body temperature (hyperthermia), which can result in liver, kidney, or cardiovascular system failure or even death.

Milk is NOT what he needs

Flakka (Alpha PVP)Use of a dangeroussynthetic cathinonedrug called alpha-pyrrolidinopentiophenone (alpha-PVP), popularly known as "Flakka," is surging in Florida and is also being reported in other parts of the country.Alpha-PVP is chemically similar to other synthetic cathinone drugs popularly called "bath salts," and takes the form of a white or pink, foul-smelling crystal.

How is Flakka AbusedFlakka can be eaten, snorted, injected, vaporized in an e-cigarette or similar device, or smoked in a joint. Vaporizing, which sends the drug very quickly into the bloodstream, may make it particularly easy to overdose.

The Chemical ReactionThe chemicals in Flakka, bind and prevent molecules on the surface of neurons, that normally keep the levels of mood-regulating neurotransmitters, dopamine and serotonin, in check. The result is to "flood the brain" with these chemicals. Cocaine and methamphetamine have similar modes of action in the brain, but the chemicals in Flakka have longer-lasting effects.Although a typical Flakka high can last one to several hours, it is possible that the neurological effects can be permanent. Not only does the drug sit on neurons, it can also destroy them. And because Flakka, like Bath Salts, hangs around in the brain for longer than cocaine, the extent of the destruction can be greater.Another serious, potentially lingering side effect of Flakka is the effect on kidneys. The drug can cause muscles to break down, as a result of hyperthermia, taking a toll on kidneys. Experts worry that some survivors of Flakka overdoses may be on dialysis for the rest of their lives.

Your Bodys Response to FlakkaLike other drugs of this type, alpha-PVP can cause a condition called "excited delirium" that involves hyper-stimulation, paranoia, and hallucinations that can lead to violent aggression and self-injury. The drug has been linked to deaths by suicide as well as heart attack. It can also dangerously raise body temperature and lead to kidney damage or kidney failure.

Signs and Symptoms of the Excited Delirium PatientModerate to severe ParanoiaExtreme Agitation/ violent behaviorShouting or making animal noisesIncreased Strength (SUPER HUMAN STRENGTH)Elevated Body Temperature/ HyperthermiaSevere Panic/ Bug EyesInsensitivity to painIncreased Thirst/ Seeking WaterNakedAttraction and/or violence toward glass and reflective surfaces

Medical Issues that can mimic Excited Delirium Panic Attacks Postictal State following a seizureDiabetic emergencyHead injuryDTSHyperthyroidismInfection/ SepsisSickle Cell crisis with Chest Pain and SOB

TREATING EsDXDo not approach patient until scene is secured by LEO. Have sufficient assistance available to manage patient.Initial Patient Assessment Protocol 2.1.1 when able to control patient.Airway Assessment/Management Protocol 2.1.2Rule out other medical issues.If attempts at verbal control are unsuccessful, use reasonable physicalUse restraints until such time as patient can be medicatedEvery attempt should be made to avoid injury to the patient when using physical restraint. If necessary, use standard restraining techniques and devices. Use sufficient padding on extremity restraints on elderly patients or others with delicate skin.Do NOT hog tie patient. Transport on side or supine . If needed have LEO ride in the back of the ambulance.Communicate in a calm non threatening manner.Attach cardiac monitor and pulse ox as soon as possible.

Chemical Sedation

Haldol (Haloperidol) An antipsychotic medication. It is used in the treatment of schizophrenia, acute psychosis, mania, delirium and other disorders.Versed (Midazolam) Is a short-acting central nervous system (CNS) depressant of the benzodiazepine class.Used for sedation in ExDS patient management.Benadryl (dipenhydramine) An antihistamine possessing sedative properties that is mainly used to treat allergies. Is commonly used as a sleep aid.The Big Three

ALS Level 1: Paramedic OnlyIf not possible to safely manage patient due to hyper-aggression and agitation, administer one of the following:Versed 2 4 mg IM / IN via atomizer (or IV if able to safely get an IV) may repeat 3 5 minutes PRN up to 10 mg.Diazepam (Valium) 5 10 mg IM (or Iv if able to safely get an IV) may repeat x 1 PRN.Haldol 5 10 mg IM (DO NOT GIVE HALDOL IV) followed by Diphenhydramine (Benadryl) 25 IM or IV. Must be on cardiac monitor.NOTE: IF Haldol unavailable OR per Med Control: Ketamine(Ketalar) 5 mg/kg IM x 1. Watch for hypersalivation/increasedbronchial secretions. Give Atropine 0.5 mg IV/IO every 5 minutes (Ketamine is on FireMed1 or Rescue 10) to maximum of 0.04 mg/kg or 3 mg totalAfter sedation, If IV has not been established before, start IV of Lactated Ringers or NS at KVO. Bolus with 250 ml increments as needed for systolic BP 120.If altered mental status, and when safe to so, determine serum glucose level with glucometer. For abnormal BGL, refer to Hyperglycemia/Hypoglycemia Protocol.

Consider Benzodiazapines (Versed, Valium) after patient is sedated and restrained and IV access established for continued sedation if needed with respiratory and cardiac in place. If altered mental status, and when safe to do so, determine serum glucose level with Glucometer or DextroStix: If sugar 60 mg/dl - 80 mg/dl; give; 100 ml 10% Dextrose IV or Glucagon 1mg IM or Sublingual glucose paste, May repeat x 1 ifafter 15 minutes recheck fingerstick glucose < 80 mg/dl If Blood sugar < 60 mg/dl; 100 - 250 ml 10% Dextrose IV or Glucagon 1 mg IM If glucose > 80 mg/dl and < 200 mg/dl, provide supportive care, keep NPO If glucose > 200 mg/dl, go to Hyperglycemia Protocol

If body temperature exceeds 102 F, move patient to cooler environment ad remove clothing. Cool aggressively with wet sheets, cool packs, and/or evaporative airflow. Lower body temperature to 102 F (39 C).If patient goes into cardiac arrest, treat accordingly and administer 1 amp Sodium Bicarb.Monitor any physically or chemically restrained patient closely for respiratory compromise and plan to intervene accordingly.

Monitor, Reassess, Treat, Monitor, Reassess and Treat some more!

Pulse Oximetry: Measurement of Oxygen saturation in the blood.Electrocardiogram (EKG): Monitoring of the heart rhythm.Temperature: Monitor initial temperature and measure decrease during cooling.End-Tidal Capnography: Measurement of Carbon Dioxide partial pressure during exhalation.Automatic Blood Pressure, Pulse and Respirations through the LifePack Monitor/Defibrillator.Mental StatusCorrect and Timely Medical Management Can Save Lives