Download I 39;m So Excited

In quantum mechanics, an excited state of a system (such as an atom, molecule or nucleus) is any quantum state of the system that has a higher energy than the ground state (that is, more energy than the absolute minimum). Excitation refers to an increase in energy level above a chosen starting point, usually the ground state, but sometimes an already excited state. The temperature of a group of particles is indicative of the level of excitation (with the notable exception of systems that exhibit negative temperature).

The lifetime of a system in an excited state is usually short: spontaneous or induced emission of a quantum of energy (such as a photon or a phonon) usually occurs shortly after the system is promoted to the excited state, returning the system to a state with lower energy (a less excited state or the ground state). This return to a lower energy level is often loosely described as decay and is the inverse of excitation.

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The ground state of the hydrogen atom has the atom's single electron in the lowest possible orbital (that is, the spherically symmetric "1s" wave function, which, so far, has been demonstrated to have the lowest possible quantum numbers). By giving the atom additional energy (for example, by absorption of a photon of an appropriate energy), the electron moves into an excited state (one with one or more quantum numbers greater than the minimum possible). If the photon has too much energy, the electron will cease to be bound to the atom, and the atom will become ionized.

After excitation the atom may return to the ground state or a lower excited state, by emitting a photon with a characteristic energy. Emission of photons from atoms in various excited states leads to an electromagnetic spectrum showing a series of characteristic emission lines (including, in the case of the hydrogen atom, the Lyman, Balmer, Paschen and Brackett series).

An atom in a high excited state is termed a Rydberg atom. A system of highly excited atoms can form a long-lived condensed excited state e.g. a condensed phase made completely of excited atoms: Rydberg matter.

A collection of molecules forming a gas can be considered in an excited state if one or more molecules are elevated to kinetic energy levels such that the resulting velocity distribution departs from the equilibrium Boltzmann distribution. This phenomenon has been studied in the case of a two-dimensional gas in some detail, analyzing the time taken to relax to equilibrium.

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Medical examiners have ruled that excited delirium caused or contributed to police-related deaths including the 2020 case of Daniel Prude in New York, the 2019 death of Julius Graves in Missouri, and the 2017 death of Adam Trammell in Wisconsin. The term came up during the 2021 trial of former Minneapolis police officer Derek Chauvin, whom jurors convicted in the death of George Floyd.

Medical examiners investigate unexpected deaths, conduct autopsies and determine causes. Some already had been moving away from excited delirium in favor of listing the multiple causes that can contribute to such deaths, including police restraint, drug use and medical conditions.

In another notable move away from the term, the Minneapolis Police Department has agreed to bar its officers from directing paramedics to inject sedatives such as ketamine into individuals they believe are experiencing excited delirium. The move came in a court agreement announced Friday by the Minnesota Department of Human Rights, which alleged the practice had been part of a pattern of racially biased policing in the city in recent years.

The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.

Objectives:Identify the etiology of excited delirium.Review the process for evaluation of excited delirium.Summarize the treatment and management options available for excited delirium.Describe interprofessional team strategies for improving care coordination and communication to improve outcomes.Access free multiple choice questions on this topic.

Delirium occurs in 11 to 42% of general medical inpatients,[10] up to 50% of the hospitalized elderly, and at even higher rates in those with pre-existing cognitive impairment, terminal illness, or receiving care in intensive care units.[11] It is common in 20% to 50% of non mechanically intensive care units and 60% to 80% of mechanically intensive care units. Patients diagnosed with delirium tend to have longer hospital stays (average 5 to 10 additional days) and are likely to be shifted to a nursing facility rather than home. They are more likely to be reintubated, if in the intensive care unit, where there is a 20% increased risk of prolonged hospitalization, and 10% increased risk of death.[12] Postoperative delirium recurs in 15% to 53% of surgical patients over 65 years of age. The incidence of delirium can reach up to 70% to 87%.[13] A 2018 review article on excited delirium syndrome, found an age range of 14 to 71, with a median age of 30 years old. Studies report 70% to 95% of cases occur in men; and that males in their mid-30s who are aggressive, impervious to pain, and display bizarre behavior represent the cohort with the highest mortality.[5]

Science does not know much about the pathophysiology of excited delirium. Based on past studies, the role of the sympathetic nervous system has been found to carry associations with the clinical picture of excited delirium. There have been observations that sympathetic nervous system activation or dysfunction controls our emotions to stress and similarly, excited delirium secondary to substance use. The neurotransmitter with which it most commonly associates is dopamine. Researchers have found elevated levels of synaptic dopamine in brains of patients suffering from Bell mania.[5]

The goals of laboratory and imaging evaluation in excited delirium syndrome are to identify an underlying causative pathology, to identify acute life-and-limb threatening pathology masked by excited delirium syndrome, and to evaluate the progression of the disease state into further physiologic derangement. Vital signs, including temperature and point-of-care serum glucose, should be obtained as soon as possible. Initial laboratory analysis should include a hepatic panel, complete blood count, and standard electrolyte panel including calcium, magnesium, and phosphorous. Ammonia level is also necessary if there is clinical or laboratory evidence of hepatotoxicity. Thyroid studies should likewise be performed as clinically indicated. Depending on clinical suspicion for infection, further studies and treatment for infection may be necessary, including serum lactate, chest radiograph, urinalysis, and blood/urine/sputum/wound cultures. Clinical suspicion for central nervous system infection should undergo an evaluation with a timely lumbar puncture. An EKG should be performed, both to diagnose acute pathology and to guide the use of treatment agents. CPK and urinalysis should be performed to assess for rhabdomyolysis. Toxic ingestion merit evaluation with toxicology screens, as well as serum acetaminophen, salicylates, and alcohol level, as clinically indicated. It is important to remember that ED toxicology testing only provides a limited picture as many drugs of abuse cannot be screened for with routine ED drug screens. Serum levels of all neurologic/psychiatric drugs that the patient is known to be taking are also beneficial in diagnosis (e.g., lithium, valproic acid, carbamazepine). CT imaging of the head is an option if there is any clinical suspicion of acute intracranial pathology. Imaging via ultrasound, radiography, and CT should be performed as indicated based on suspected or identified injuries. The injuries may be the cause of the excited delirium or a result of the disease state. Cardiac enzymes may be added depending on clinical suspicion of myocardial injury and EKG changes.[9]

In most clinical settings, intervention is often necessary without a complete history and physical exam. Treatment strategies require tailoring to different patient populations, including pediatrics, geriatrics, and obstetric populations. There is some debate regarding optimal first-line agents in diverse populations. As of the time of this authorship the Florida Regional Common EMS Protocol recommends 4 mg/kg IM ketamine for violent and agitated patients with excited delirium syndrome, with options for midazolam, lorazepam, diazepam, diphenhydramine, and haloperidol via various routes based on paramedic judgment.[14] First-line agents for acute agitation in an adult patient include an antipsychotic (droperidol, haloperidol, ziprasidone, risperidone or olanzapine) plus a benzodiazepine (midazolam or lorazepam). Haloperidol and droperidol carry a significant risk of QT prolongation and associated cardiac events, especially in patients on psychiatric medication or with electrolyte abnormalities.[15] 2351a5e196