Death from MDPV-associated excited delirium
February 11, 2012, 5:05 pm
Death Following Recreational Use of Designer Drug “Bath Salts” Containing 3,4,-Methylenedioxypyrovalerone (MDPV). Murray BL et al. J Med Toxicol 2012 Jan 20 [Epub ahead of print}
This very interesting case report describes a 40-year-old male who developed excited delirium syndrome after snorting and injecting a "bath salt" product later found to contain the synthetic cathinone MDPV, as well as trimethoprim. As Takeuchi et al point out in their superb review of the topic, excited delirium presents with a typical sequence of events:
[Excited delirium] describe[s] almost the exact same sequence of events: delirium with agitation (fear, panic, shouting, violence and hyperactivity), sudden cessation of struggle, respiratory arrest and death. In the majority of cases unexpected strength and signs of hyperthermia are described as well.
Most cases of excited delirium follow use of stimulant drugs such as MDMA, cocaine and methamphetamine.
In the case reported here, the patient presented initially with a rectal temperature of 105.4oF and hyperkalemia (K = 7.4 mmol/L). It is obvious from the description that his presentation overwhelmed the initial hospital. After surviving a cardiac arrest, he was transferred to a tertiary hospital but suffered severe hypoxic encephalopathy and was declared brain dead 2 days after his initial presentation.
Some take-home lessons from this case:
- It is essential to get control of these patients immediately, using physical restraints if necessary but switching as soon as possible. (The Takeuchi article has a good discussion of chemical restraint options in these patients.)
- In excited delirium, anticipate hyperthermia, rhabdomyolysis, renal failure, hyperkalemia, metabolic acidosis, coagulapathy, and sudden deterioration.
- When a patient with excited delirium “gives up” and stops struggling before chemical restraints have been instituted, expect rapid onset of respiratory and cardiac arrest.
This clip from the TV series “Washington’s Most Wanted” shows several dramatic episodes of excited delirium, and describes Seattle’s procedure of responding to these events with both police and medical personnel:
Life in the Fast Lane has an excellent discussion of excited delirium. EMCrit podcast has a episode on how to take down a violent, agitated delirium patient. The show notes for that episode link to the following video on the proper safe way to apply physical restraints — always a stopgap measure until chemical restraint can be accomplished: