“Excited delirium” is not a legitimate medical diagnosis

Current evidence does not support the use of “excited delirium“or” excited delirium syndrome “as a medical diagnosis, the American Medical Association (AMA) said today, and the term should not be used unless clear diagnostic criteria are validated.

The term is disproportionately applied to people of color, “for whom inappropriate and excessive drug therapy continues to be the norm instead of behavioral de-escalation,” said the report from WADA’s Council for Science and Technology. public health (CSAPH), and is therefore indicative of systemic racism.

This conclusion was one of many CSAPH 2 report, which was adopted today at the special meeting of the WADA House of Delegates.

WADA also opposes “the use of sedative/ hypnotic and dissociative agents, including ketamine, as a pharmacological intervention for restless people outside the hospital, when performed only for law enforcement purposes. “

Medicines typically used for restraint include dissociative ketamine, benzodiazepine sedatives such as midazolam, and antipsychotic drugs, including olanzapine Where haloperidol, alone or in combination.

Kenneth Certa, MD, of the American Psychiatric Association, speaking on behalf of the Section’s Psychiatry Board, said at a reference committee hearing: “Over the years we have been very concerned about the development of the inaccurate diagnosis of “excited delirium” “excited delirium”, especially after having killed a number of individuals, more than what is reported in the press, by the use of ketamine in the field for this inaccurate diagnosis. “

Tamaan Osbourne-Roberts, MD, delegate and CSAPH member, said the diagnosis lacks scientific evidence and is “disproportionately applied to otherwise healthy black men in their mid-thirties and these men are most likely to die from the actions of the resulting first responders “.

Osbourne-Roberts testified that de-escalation training should be used more widely and that crisis intervention team models in which behavioral health specialists are first deployed to respond to behavioral health emergencies should be more widespread.

Andrew Rudawsky, MD, deputy medical director of two emergency departments and a delegate from Ohio, speaking in a personal capacity, testified: “I can tell you from firsthand experience that ‘excited delirium’ is very real. These very sick and unstable patients have an emergency medical condition best treated by an emergency doctor. “

The report recognizes that drugs used outside a hospital by non-physicians carry significant risks, especially for people with underlying illnesses and in terms of drug interactions.

I totally agree that medicine should not be practiced by law enforcement.

“I totally agree that medicine should not be practiced by law enforcement,” Rudawsky said. “I am seriously concerned about the legal ramifications of stating that this condition does not exist.”

He said he was optimistic that the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be updated to include “excited delirium”.

The report urges medical and behavioral health specialists, instead of law enforcement, to serve as first responders and decision makers in medical and mental health emergencies in local communities.

In addition, the report urges that “the administration of any pharmacological treatment outside the hospital be done in a fair, evidence-based, anti-racist and stigma-free manner”.

The report calls on law enforcement and frontline emergency medical service personnel, who are part of the “double response” in emergencies, to undergo training overseen by EMS medical directors. “The training should at a minimum include de-escalation techniques and the appropriate use of pharmacological intervention for agitated people outside the hospital,” the report said.

Controversy over surveillance recommendation

Several responders were emergency physicians and medical directors who feared that the investigation of potential cases of inappropriate pharmacological intervention would be overseen by non-physicians.

The CSAPH authors write that independent investigators are appropriate, while those in emergency medicine say EMS medical directors should lead the surveillance.

Stephen Epstein, MD, chair of the section council on emergency medicine, speaking on behalf of the section board, had called for the referral of the part of the report that deals with EMS surveillance.

“We are concerned that Recommendation 6, by bringing in independent investigators, would put non-physicians in the position of overseeing the practice of medicine in a specialty approved by the board. It would set an unfortunate precedent for our WADA.” , did he declare.

Epstein also said that the American College of Emergency Physicians will soon release a report on “excited delirium,” which will add key information to discuss the issue.

He added that a new report on the safety of ketamine in out-of-hospital use has been published last week in the Annals of Emergency Medicine. The authors have reviewed over 11,000 cases of pharmacological intervention over the past 2 years.

“We believe this information can add significantly to the recommendation of this report,” Epstein said.

Recommendation 6 was referred to WADA’s Board of Directors for decision, but the remainder of the report was adopted by an overwhelming majority.

Certa, Osbourne-Roberts, Rudawsky and Epstein did not report any relevant financial relationships.

Marcia Frellick is a freelance journalist based in Chicago. She previously wrote for the Chicago Tribune, Science News, and Nurse.com, and was an editor for the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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