Excited delirium: Difference between revisions
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*Agitation: Physical and Chemical sedation | *Agitation: Physical and Chemical sedation | ||
**Benzodiazipines, Neuroleptics | **Benzodiazipines, 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> | **[[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 | ***4-5mg/kg IM | ||
***1-2mg/kg IV | ***1-2mg/kg IV | ||
**Case reports using dantrolene<ref>Allam, S: Cocaine-excited delirium and severe acidosis. Anaesthesia. 2001 Apr; 56(4):385-6</ref> | **Case reports using dantrolene<ref>Allam, S: Cocaine-excited delirium and severe acidosis. Anaesthesia. 2001 Apr; 56(4):385-6</ref> | ||
**Consider IV olanzapine 2.5-5mg IV q5-10min to max dose of 20mg | **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) | ***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 | ***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 | ***IV olanzapine may be as safe or safer than IM, with faster onset | ||
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==External Links== | ==External Links== | ||
*[http://lifeinthefastlane.com/crazy-then-dead/ LITFL: Crazy….Then Dead!] | *[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?] | *[http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/ PulmCrit: Intravenous olanzapine: Faster than IM olanzapine, safer than IV [[haloperidol]]?] | ||
==See Also== | ==See Also== | ||
Revision as of 15:58, 3 August 2016
Background
- Also known as agitated delirium
- Controversial diagnosis, not recognized by DSM 4 or ICD 9
- 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: reversal of clinical and lab abnormalities
- Hyperthermia: Remove clothing, misting/airflow, ice packs , cold IV fluids
- Acidosis: IV fluids; bicarb controversial
- Rhabdomyolysis: IV fluids
- Hyperkalemia
- Agitation: Physical and Chemical sedation
- Benzodiazipines, 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
- Case reports using dantrolene[5]
- 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?
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.
- ↑ Allam, S: Cocaine-excited delirium and severe acidosis. Anaesthesia. 2001 Apr; 56(4):385-6