Excited 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

Management

Supportive care

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

See Also

References
  1. ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009
  2. Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83
  3. 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
  4. Cole JB, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol. 2016 Apr 21. Epub ahead of print.
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