Excited Delirium

Agitation
1. Behavior that is loud, hyperactive, disruptive, threatening or disruptive
Agitated Delirium (Excited Delirium)
1. Psychomotor Agitation, Delirium and sweating often accompanied by Violent Behavior, increased strength, hyperthermia

First described by Dr. Luther Bell in the 1849 (Bell's Mania)
1. Described Excited Delirium in institutionalized patients

Excited Delirium patients are at high risk of injuring others
Emergency department healthcare workers are at risk of injury
1. Emergency Department may exacerbate Agitation (noisy, chaotic environment with long waits)
2. Physical assaults on Emergency healthcare workers are frequent
Excited Delirium has a very high mortality rate (due to Dysrhythmia, acidosis, Rhabdomyolysis)
1. Typically follows patient becoming suddenly calm in restraints
2. Cardiac Arrest ensues (PEA, brady-Asystole)

Sudden onset of Agitation
Local law enforcement called to scene of Agitated Patient
1. Does not respond to authorities or verbal commands
2. Continues to resist with significant force despite Physical Restraints
Violent, combative, belligerent or assaulting others
1. Minimal response to painful stimuli
2. Superhuman strength
3. Destroys inaminate objects
4. Walks or runs into oncoming traffic without regard for safety
Psychosis, Delirium and Psychomotor Agitation
1. Delusional
2. Visual Hallucinations
3. Paranoid or fearful
4. Yelling, shouting or making guttural sounds
5. Disrobes or wears inappropriate clothing
Hypersympathetic Syndrome
1. Profuse diaphoresis
2. Tachypnea
3. Tachycardia
4. Hyperthermia
5. Hypertension

Rhabdomyolysis
Severe Metabolic Acidosis
Death
1. Immediately follows period of tranquility (patient appears to have given up)
2. Sudden collapse in restraints with cardiopulmonary arrest (PEA, brady-Asystole)
3. Aggressive Resuscitation efforts are often unsuccessful

Local law enforcement
1. Recognize possible Excited Delirium
2. Call for EMS early
3. Contain the subject (requires multiple officers)
  1. Expect subject to not respond to painful maneuvers
Emergency Medical Services (EMS)
1. Note hyperthermia on presentation (may predict sudden death)
2. Transport to emergency department for definitive care
3. Mangement is based on local protocol (examples listed below)
4. Evaluate for easily reversible causes
  1. Bedside Glucose (Hypoglycemia)
  2. Hypoxia (Oxygen Saturation)
5. Sedation (choose one)
  1. Ketamine 2 mg/kg IV or 5 mg/kg IM
    1. Does not require intubation (unless otherwise indicated), but closely monitor
  2. Midazolam 2 mg IV, 5 mg IM or 5 mg intranasal (preferred Benzodiazepine for rapid onset)
6. Other measures
  1. Normal Saline 500 to 1000 cc fluid bolus
  2. External cooling (Evaporative Cooling, cold packs)
7. Consider coingestions
  1. Identify Toxidromes
  2. Heroin with Cocaine (Speedball)
  3. If Opioid reversal is needed, use small Naloxone doses (1 mg in 10 cc) 0.1 mg at a time
    1. Rapid reversal with large Naloxone doses could exacerbate Agitation

Safely and quickly contain the patient
1. See Sedation of the Violent Patient
2. See Physical Restraint
3. Initiate sedation (and Advanced Airway if needed)
  1. See Sedation in Excited Delirium (as well as doses under EMS as above)
  2. Ketamine and Benzodiazepines are most commonly used
  3. Use Antipsychotics (e.g. Zyprexa, Haldol) only with caution (QT Prolongation risk)
Treat Hyperthermia
1. Evaporative Cooling with fans and misting
2. Cool saline bags applied to groin and axilla
3. Cold IV saline infusion
4. Ice water rectal enemas
5. Ice water immersion
Treat Metabolic Acidosis
1. Maximize oxygenation and hydration
2. Sodium Bicarbonate may be used for significant acidosis (controversial)
Other measures
1. Bedside Glucose
2. Unknown Ingestion evaluation
3. Consider Differential Diagnosis (see above)
4. Rhabdomyolysis management as indicated
5. Monitor for Dysrhythmia
  1. Bradycardia may precede PEA or Asystole