Excited delirium
(Redirected from Agitated delirium)
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.