Excited Delirium

1. See Also
   1. Altered Level of Consciousness
   2. Violent Behavior
   3. Psychosis
   4. Agitation
   5. Sedation in Excited Delirium
   6. Physical Restraint
   7. Emergency Psychiatric Evaluation
2. Definitions
   1. Agitation
      1. Behavior that is loud, hyperactive, disruptive, threatening or disruptive
   2. Agitated Delirium (Excited Delirium)
      1. Psychomotor Agitation, Delirium and sweating often accompanied by Violent Behavior, increased strength, hyperthermia
3. Epidemiology
   1. Male gender most common
   2. Mean age mid-30s
4. History
   1. First described by Dr. Luther Bell in the 1849 (Bell's Mania)
      1. Described Excited Delirium in institutionalized patients
5. Pathophysiology
   1. Typically triggered by stimulant drug use (Cocaine, Methamphetamine, PCP)
   2. May be related to excessive Dopamine stimulation in the corpus striatum
6. Associated Conditions
   1. Psychostimulant abuse (e.g. Cocaine, Methamphetamine)
   2. Mental Illness (e.g. Schizophrenia, Bipolar Disorder)
7. Precautions
   1. Excited Delirium patients are at high risk of injuring others
   2. 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
   3. 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)
8. Signs
   1. Sudden onset of Agitation
   2. 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
   3. 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
   4. 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
   5. Hypersympathetic Syndrome
      1. Profuse diaphoresis
      2. Tachypnea
      3. Tachycardia
      4. Hyperthermia
      5. Hypertension
9. Exam: Agitation rating scales
   1. Agitated Behavior Scale
   2. Behavioral Activity Rating Scale
   3. Broset Violence Checklist
10. Diagnostics
    1. Vital Sign monitoring (esp. Body Temperature, Blood Pressure, Heart Rate, Oxygen Saturation)
    2. Continuous cardiac monitor
    3. Electrocardiogram
       1. Evaluate for QRS Widening, QTc Prolongation
11. Labs
    1. See Unknown Ingestion
    2. Bedside Glucose
    3. Comprehensive Metabolic Panel
    4. Complete Blood Count
    5. Urinalysis
    6. Urine Pregnancy Test (as indicated)
    7. Toxicology Screening
       1. Urine Drug Screen
       2. Blood Alcohol Level
       3. Acetaminophen Level
       4. Salicylate Level
    8. Creatinine Phosphokinase (CPK)
       1. Increased in Rhabdomyolysis
    9. Venous Blood Gas
       1. Metabolic Acidosis
12. Differential Diagnosis: "Hot and Bothered Patient" (Agitation, Fever, Hypertension, Tachycardia)
    1. See Sympathomimetic Toxicity
    2. See Altered Mental Status Differential Diagnosis
    3. See Violent Behavior
    4. See Psychosis
    5. See Delirium
    6. Trauma
       1. Intracranial Hemorrhage (Acute Subdural Hematoma, Subarachnoid Hemorrhage)
    7. Thermoregulation
       1. Heat Stroke
       2. Hypothermia
    8. Toxicology (Intoxication, Drug Withdrawal)
       1. Serotonin Syndrome
       2. Neuroleptic Malignant Syndrome
       3. Malignant Hyperthermia
       4. Sympathomimetic Toxicity
       5. Anticholinergic Toxicity
       6. Alcohol Withdrawal
       7. Benzodiazepine Withdrawal
    9. Substances
       1. Cocaine
       2. Methamphetamine
       3. Synthetic Cathinone (Psychoactive Bath Salts)
       4. Methylenedioxymethamphetamine (Ecstasy, MDMA)
       5. Phencyclidine (PCP)
       6. Ketamine
    10. Metabolic
        1. Thyrotoxicosis
        2. Hypoglycemia
        3. Hyperglycemia
    11. Infection
        1. Encephalitis
        2. Meningitis
        3. Sepsis
    12. Respiratory
        1. Hypoxia
        2. Hypercarbia
13. Complications
    1. Rhabdomyolysis
    2. Severe Metabolic Acidosis
    3. 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
14. Imaging
    1. Consider Head CT (and if Trauma, Cervical Spine CT)
15. Management: Pre-hospital
    1. 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
    2. 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
16. Management: Emergency Department
    1. 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)
    2. 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
    3. Treat Metabolic Acidosis
       1. Maximize oxygenation and hydration
       2. Sodium Bicarbonate may be used for significant acidosis (controversial)
    4. 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
17. Resources
    1. ACEP White Paper: Excited Delirium
       1. http://www.fmhac.net/assets/documents/2012/presentations/krelsteinexciteddelirium.pdf
18. References
    1. Farah and Herbert in Swadron (2022) EM:Rap 22(5): 12-3
    2. Roppolo, Klinger, Leaf (2019) Crit Dec Emerg Med 33(2): 3-10
    3. Takeuchi (2011) West J Emerg Med 12(1): 77–83 [PubMed]