Excited delirium: Difference between revisions
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==Background== | ==Background== | ||
*Also known as agitated delirium | *Also known as agitated delirium | ||
*Controversial diagnosis, not recognized by DSM 4 or ICD 9 | *Controversial diagnosis, not recognized by DSM 4/5 or ICD 9/10 | ||
*Recognized by ACEP in 2009<ref name="ACEP">ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009</ref> | *Recognized by ACEP in 2009<ref name="ACEP">ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009</ref> | ||
*Agitation, aggression, acute distress, often in pre-hospital setting including police custody<ref name="WestJEM">Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83</ref> | *Agitation, aggression, acute distress, often in pre-hospital setting including police custody<ref name="WestJEM">Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83</ref> | ||
*Associate with hyperthermia, drug use and sometimes death<ref name="WestJEM"/> | *Associate with hyperthermia, drug use and sometimes death<ref name="WestJEM"/> | ||
==Clinical Features<ref name="ACEP"/>== | ==Clinical Features<ref name="ACEP"/>== | ||
*Triad of delirium, psychomotor agitation and physiological excitation | *Triad of [[delirium]], psychomotor [[agitation]] and physiological excitation | ||
*Associated with drug use: [[cocaine]] (#1), methamphetamine, [[alcohol]], [[PCP]], [[LSD]] | *Associated with drug use: [[cocaine]] (#1), [[methamphetamine]], [[alcohol]], [[PCP]], [[LSD]] | ||
*Associated with mental health disease | *Associated with mental health disease | ||
*Typically male, mean age 30's | *Typically male, mean age 30's | ||
| Line 17: | Line 17: | ||
*[[Hyperthermia]] | *[[Hyperthermia]] | ||
*[[Altered Mental Status (AMS)]] | *[[Altered Mental Status (AMS)]] | ||
== | ==Evaluation== | ||
*Typical clinical features associated with | *Typical clinical features associated with | ||
*Tachycardia | *[[Tachycardia]] | ||
*Tachypnea | *[[Tachypnea]] | ||
*[[Hyperthermia]] | *[[Hyperthermia]] | ||
*Acidosis | *[[Acidosis]] | ||
*[[Rhabdomyolysis]] | *[[Rhabdomyolysis]] | ||
==Management== | ==Management== | ||
===Supportive care=== | |||
*Evaluation for reversible clinical and lab abnormalities | |||
*[[Hyperthermia]]: Remove clothing, misting/airflow, ice packs , cold IV fluids | |||
*[[Metabolic Acidosis|Acidosis]]: IV fluids; bicarb controversial | |||
*[[Rhabdomyolysis]]: IV fluids | |||
* | *[[Hyperkalemia]] | ||
* | ===Agitation Reduction=== | ||
*Prioritize chemical sedation although some physical restraint is always required | |||
*[[Benzodiazepines]], [[Neuroleptics]] | |||
*[[Ketamine]] use increasingly described<ref>Roberts, J: Emergency Medicine News website. http://journals.lww.com/em-news/Fulltext/2015/12000/InFocus__Ketamine_an_Ideal_Treatment_for_Excited.18.aspx Unknown published date. Accessed Dec 13, 2015</ref> but may be related with increased side effects such as intubation when used at max IM dosing<ref>Cole JB, et al. A prospective study of ketamine versus [[haloperidol]] for severe prehospital agitation. Clin Toxicol. 2016 Apr 21. Epub ahead of print.</ref> | |||
** | **4-5mg/kg IM | ||
**1-2mg/kg IV | |||
*Consider IV [[olanzapine]] 2.5-5mg IV q5-10min to max dose of 20mg | |||
**In place of IV [[haloperidol]], which is approximately half as potent (~5-10mg [[haloperidol]] = ~2.5-5mg olanzapine) | |||
**May be safer in patients with prolonged QTc or those too agitated to obtain ECG | |||
**IV [[olanzapine]] may be as safe or safer than IM, with faster onset | |||
==Disposition== | ==Disposition== | ||
*Based on severity of clinical presentation and response to treatment | *Based on severity of clinical presentation and response to treatment | ||
==External Links== | |||
*[http://lifeinthefastlane.com/crazy-then-dead/ LITFL: Crazy….Then Dead!] | |||
*[http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/ PulmCrit: Intravenous olanzapine: Faster than IM olanzapine, safer than IV [[haloperidol]]?] | |||
==Medication Dosing== | |||
*{{MedicationDose|drug=Ketamine|dose=4-5 mg/kg|route=IM|context=Chemical sedation for excited delirium|indication=Excited delirium|population=Adult|notes=Increasingly used; may increase intubation rate at max doses}} | |||
*{{MedicationDose|drug=Midazolam|dose=5 mg|route=IM|context=Benzodiazepine sedation|indication=Excited delirium|population=Adult}} | |||
==See Also== | ==See Also== | ||
*[[Altered mental status]] | |||
*[[Agitated or combative patient]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Psychiatry]][[Category:Toxicology]] | |||
Latest revision as of 17:58, 20 March 2026
Background
- Also known as agitated delirium
- Controversial diagnosis, not recognized by DSM 4/5 or ICD 9/10
- Recognized by ACEP in 2009[1]
- Agitation, aggression, acute distress, often in pre-hospital setting including police custody[2]
- Associate with hyperthermia, drug use and sometimes death[2]
Clinical Features[1]
- Triad of delirium, psychomotor agitation and physiological excitation
- Associated with drug use: cocaine (#1), methamphetamine, alcohol, PCP, LSD
- Associated with mental health disease
- Typically male, mean age 30's
- Violent, combative, belligerent, bizarre behavior
- Resistant to physical restraint, superhuman strength
- Associated with cardiopulmonary arrest
Differential Diagnosis
Evaluation
- Typical clinical features associated with
- Tachycardia
- Tachypnea
- Hyperthermia
- Acidosis
- Rhabdomyolysis
Management
Supportive care
- Evaluation for reversible clinical and lab abnormalities
- Hyperthermia: Remove clothing, misting/airflow, ice packs , cold IV fluids
- Acidosis: IV fluids; bicarb controversial
- Rhabdomyolysis: IV fluids
- Hyperkalemia
Agitation Reduction
- Prioritize chemical sedation although some physical restraint is always required
- Benzodiazepines, Neuroleptics
- Ketamine use increasingly described[3] but may be related with increased side effects such as intubation when used at max IM dosing[4]
- 4-5mg/kg IM
- 1-2mg/kg IV
- Consider IV olanzapine 2.5-5mg IV q5-10min to max dose of 20mg
- In place of IV haloperidol, which is approximately half as potent (~5-10mg haloperidol = ~2.5-5mg olanzapine)
- May be safer in patients with prolonged QTc or those too agitated to obtain ECG
- IV olanzapine may be as safe or safer than IM, with faster onset
Disposition
- Based on severity of clinical presentation and response to treatment
External Links
- LITFL: Crazy….Then Dead!
- PulmCrit: Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol?
Medication Dosing
- Ketamine 4-5 mg/kg IM — Increasingly used; may increase intubation rate at max doses
- Midazolam 5 mg IM
See Also
References
- ↑ 1.0 1.1 ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009
- ↑ 2.0 2.1 Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83
- ↑ Roberts, J: Emergency Medicine News website. http://journals.lww.com/em-news/Fulltext/2015/12000/InFocus__Ketamine_an_Ideal_Treatment_for_Excited.18.aspx Unknown published date. Accessed Dec 13, 2015
- ↑ Cole JB, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol. 2016 Apr 21. Epub ahead of print.