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Excited Delirium
Aka: Excited Delirium, Agitated Delirium, Bell's Mania
- See Also
- Altered Level of Consciousness
- Violent Behavior
- Psychosis
- Agitation
- Sedation in Excited Delirium
- Physical Restraint
- Emergency Psychiatric Evaluation
- Definitions
- Agitation
- Behavior that is loud, hyperactive, disruptive, threatening or disruptive
- Agitated Delirium (Excited Delirium)
- Psychomotor Agitation, Delirium and sweating often accompanied by Violent Behavior, increased strength, hyperthermia
- Epidemiology
- Male gender most common
- Mean age mid-30s
- History
- First described by Dr. Luther Bell in the 1849 (Bell's Mania)
- Described Excited Delirium in institutionalized patients
- Pathophysiology
- Typically triggered by stimulant drug use (Cocaine, Methamphetamine, PCP)
- May be related to excessive Dopamine stimulation in the corpus striatum
- Associated Conditions
- Psychostimulant abuse (e.g. Cocaine, Methamphetamine)
- Mental Illness (e.g. Schizophrenia, Bipolar Disorder)
- Precautions
- Excited Delirium patients are at high risk of injuring others
- Emergency department healthcare workers are at risk of injury
- Emergency Department may exacerbate Agitation (noisy, chaotic environment with long waits)
- Physical assaults on Emergency healthcare workers are frequent
- Excited Delirium has a very high mortality rate (due to Dysrhythmia, acidosis, Rhabdomyolysis)
- Typically follows patient becoming suddenly calm in restraints
- Cardiac Arrest ensues (PEA, brady-Asystole)
- Signs
- Sudden onset of Agitation
- Local law enforcement called to scene of Agitated Patient
- Does not respond to authorities or verbal commands
- Continues to resist with significant force despite Physical Restraints
- Violent, combative, belligerent or assaulting others
- Minimal response to painful stimuli
- Superhuman strength
- Destroys inaminate objects
- Walks or runs into oncoming traffic without regard for safety
- Psychosis, Delirium and Psychomotor Agitation
- Delusional
- Visual Hallucinations
- Paranoid or fearful
- Yelling, shouting or making guttural sounds
- Disrobes or wears inappropriate clothing
- Hypersympathetic Syndrome
- Profuse diaphoresis
- Tachypnea
- Tachycardia
- Hyperthermia
- Hypertension
- Exam: Agitation rating scales
- Agitated Behavior Scale
- Behavioral Activity Rating Scale
- Broset Violence Checklist
- Diagnostics
- Vital Sign monitoring (esp. Body Temperature, Blood Pressure, Heart Rate, Oxygen Saturation)
- Continuous cardiac monitor
- Electrocardiogram
- Evaluate for QRS Widening, QTc Prolongation
- Labs
- See Unknown Ingestion
- Bedside Glucose
- Comprehensive Metabolic Panel
- Complete Blood Count
- Urinalysis
- Urine Pregnancy Test (as indicated)
- Toxicology Screening
- Urine Drug Screen
- Blood Alcohol Level
- Acetaminophen Level
- Salicylate Level
- Creatinine Phosphokinase (CPK)
- Increased in Rhabdomyolysis
- Venous Blood Gas
- Metabolic Acidosis
- Differential Diagnosis: "Hot and Bothered Patient" (Agitation, Fever, Hypertension, Tachycardia)
- See Sympathomimetic Toxicity
- See Altered Mental Status Differential Diagnosis
- See Violent Behavior
- See Psychosis
- See Delirium
- Trauma
- Intracranial Hemorrhage (Acute Subdural Hematoma, Subarachnoid Hemorrhage)
- Thermoregulation
- Heat Stroke
- Hypothermia
- Toxicology (Intoxication, Drug Withdrawal)
- Serotonin Syndrome
- Neuroleptic Malignant Syndrome
- Malignant Hyperthermia
- Sympathomimetic Toxicity
- Anticholinergic Toxicity
- Alcohol Withdrawal
- Benzodiazepine Withdrawal
- Substances
- Cocaine
- Methamphetamine
- Synthetic Cathinone (Psychoactive Bath Salts)
- Methylenedioxymethamphetamine (Ecstasy, MDMA)
- Phencyclidine (PCP)
- Ketamine
- Metabolic
- Thyrotoxicosis
- Hypoglycemia
- Hyperglycemia
- Infection
- Encephalitis
- Meningitis
- Sepsis
- Respiratory
- Hypoxia
- Hypercarbia
- Complications
- Rhabdomyolysis
- Severe Metabolic Acidosis
- Death
- Immediately follows period of tranquility (patient appears to have given up)
- Sudden collapse in restraints with cardiopulmonary arrest (PEA, brady-Asystole)
- Aggressive Resuscitation efforts are often unsuccessful
- Imaging
- Consider Head CT (and if Trauma, Cervical Spine CT)
- Management: Pre-hospital
- Local law enforcement
- Recognize possible Excited Delirium
- Call for EMS early
- Contain the subject (requires multiple officers)
- Expect subject to not respond to painful maneuvers
- Emergency Medical Services (EMS)
- Note hyperthermia on presentation (may predict sudden death)
- Transport to emergency department for definitive care
- Mangement is based on local protocol (examples listed below)
- Evaluate for easily reversible causes
- Bedside Glucose (Hypoglycemia)
- Hypoxia (Oxygen Saturation)
- Sedation (choose one)
- Ketamine 2 mg/kg IV or 5 mg/kg IM
- Does not require intubation (unless otherwise indicated), but closely monitor
- Midazolam 2 mg IV, 5 mg IM or 5 mg intranasal (preferred Benzodiazepine for rapid onset)
- Other measures
- Normal Saline 500 to 1000 cc fluid bolus
- External cooling (Evaporative Cooling, cold packs)
- Consider coingestions
- Identify Toxidromes
- Heroin with Cocaine (Speedball)
- If Opioid reversal is needed, use small Naloxone doses (1 mg in 10 cc) 0.1 mg at a time
- Rapid reversal with large Naloxone doses could exacerbate Agitation
- Management: Emergency Department
- Safely and quickly contain the patient
- See Sedation of the Violent Patient
- See Physical Restraint
- Initiate sedation (and Advanced Airway if needed)
- See Sedation in Excited Delirium (as well as doses under EMS as above)
- Ketamine and Benzodiazepines are most commonly used
- Use Antipsychotics (e.g. Zyprexa, Haldol) only with caution (QT Prolongation risk)
- Treat Hyperthermia
- Evaporative Cooling with fans and misting
- Cool saline bags applied to groin and axilla
- Cold IV saline infusion
- Ice water rectal enemas
- Ice water immersion
- Treat Metabolic Acidosis
- Maximize oxygenation and hydration
- Sodium Bicarbonate may be used for significant acidosis (controversial)
- Other measures
- Bedside Glucose
- Unknown Ingestion evaluation
- Consider Differential Diagnosis (see above)
- Rhabdomyolysis management as indicated
- Monitor for Dysrhythmia
- Bradycardia may precede PEA or Asystole
- Resources
- ACEP White Paper: Excited Delirium
- http://www.fmhac.net/assets/documents/2012/presentations/krelsteinexciteddelirium.pdf
- References
- Farah and Herbert in Swadron (2022) EM:Rap 22(5): 12-3
- Roppolo, Klinger, Leaf (2019) Crit Dec Emerg Med 33(2): 3-10
- Takeuchi (2011) West J Emerg Med 12(1): 77–83 [PubMed]