Excited delirium - Revision history

Danbot: Add MedicationDose SMW entries for ketamine and midazolam; doses verified against EM/toxicology guidelines

2026-03-20T17:58:53Z

Add MedicationDose SMW entries for ketamine and midazolam; doses verified against EM/toxicology guidelines

← Older revision		Revision as of 17:58, 20 March 2026
Line 48:		Line 48:
	*[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]]?]


			==Medication Dosing==
			*{{MedicationDose\|drug=Ketamine\|dose=4-5 mg/kg\|route=IM\|context=Chemical sedation for excited delirium\|indication=Excited delirium\|population=Adult\|notes=Increasingly used; may increase intubation rate at max doses}}
			*{{MedicationDose\|drug=Midazolam\|dose=5 mg\|route=IM\|context=Benzodiazepine sedation\|indication=Excited delirium\|population=Adult}}

	==See Also==		==See Also==

Rossdonaldson1: /* See Also */

2022-08-31T16:08:21Z

ClaireLewis at 17:03, 10 October 2019

2019-10-10T17:03:53Z

← Older revision		Revision as of 17:03, 10 October 2019
Line 6:		Line 6:
	*Associate with hyperthermia, drug use and sometimes death<ref name="WestJEM"/>		*Associate with hyperthermia, drug use and sometimes death<ref name="WestJEM"/>
	==Clinical Features<ref name="ACEP"/>==		==Clinical Features<ref name="ACEP"/>==
	*Triad of delirium, psychomotor agitation and physiological excitation		*Triad of [[delirium]], psychomotor [[agitation]] and physiological excitation
	*Associated with drug use: [[cocaine]] (#1), methamphetamine, [[alcohol]], [[PCP]], [[LSD]]		*Associated with drug use: [[cocaine]] (#1), [[methamphetamine]], [[alcohol]], [[PCP]], [[LSD]]
	*Associated with mental health disease		*Associated with mental health disease
	*Typically male, mean age 30's		*Typically male, mean age 30's
Line 19:		Line 19:
	==Evaluation==		==Evaluation==
	*Typical clinical features associated with		*Typical clinical features associated with
	*Tachycardia		*[[Tachycardia]]
	*Tachypnea		*[[Tachypnea]]
	*[[Hyperthermia]]		*[[Hyperthermia]]
	*Acidosis		*[[Acidosis]]
	*[[Rhabdomyolysis]]		*[[Rhabdomyolysis]]
	==Management==		==Management==
	===Supportive care===		===Supportive care===
	*Evaluation for ~~reversable~~ clinical and lab abnormalities		*Evaluation for reversible clinical and lab abnormalities
	*[[Hyperthermia]]: Remove clothing, misting/airflow, ice packs , cold IV fluids		*[[Hyperthermia]]: Remove clothing, misting/airflow, ice packs , cold IV fluids
	*[[Metabolic Acidosis\|Acidosis]]: IV fluids; bicarb controversial		*[[Metabolic Acidosis\|Acidosis]]: IV fluids; bicarb controversial

Ostermayer: /* Management */

2019-05-13T17:41:58Z

Management

← Older revision		Revision as of 17:41, 13 May 2019
Line 33:		Line 33:
	===Agitation Reduction===		===Agitation Reduction===
	*Prioritize chemical sedation although some physical restraint is always required		*Prioritize chemical sedation although some physical restraint is always required
	*[[~~Benzodiazipines~~]], [[Neuroleptics]]		*[[Benzodiazepines]], [[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

Ostermayer: /* Management */

2019-05-13T17:41:06Z

Management

← Older revision		Revision as of 17:41, 13 May 2019
Line 25:		Line 25:
	*[[Rhabdomyolysis]]		*[[Rhabdomyolysis]]
	==Management==		==Management==
	*Supportive care~~: reversal of~~ clinical and lab abnormalities		===Supportive care===
	**[[Hyperthermia]]: Remove clothing, misting/airflow, ice packs , cold IV fluids		*Evaluation for reversable clinical and lab abnormalities
	**[[Metabolic Acidosis\|Acidosis]]: IV fluids; bicarb controversial		*[[Hyperthermia]]: Remove clothing, misting/airflow, ice packs , cold IV fluids
	**[[Rhabdomyolysis]]: IV fluids		*[[Metabolic Acidosis\|Acidosis]]: IV fluids; bicarb controversial
	**[[Hyperkalemia]]		*[[Rhabdomyolysis]]: IV fluids
	*~~Agitation: Physical and Chemical~~ sedation		*[[Hyperkalemia]]
	**Benzodiazipines, Neuroleptics		===Agitation Reduction===
	**[[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>		*Prioritize chemical sedation although some physical restraint is always required
	***4-5mg/kg IM		*[[Benzodiazipines]], [[Neuroleptics]]
	***1-2mg/kg IV		*[[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>
	**Case reports using dantrolene<ref>Allam, S: Cocaine-excited delirium and severe acidosis. Anaesthesia. 2001 Apr; 56(4):385-6</ref>		**4-5mg/kg IM
	**Consider IV [[olanzapine]] 2.5-5mg IV q5-10min to max dose of 20mg		**1-2mg/kg IV
	***In place of IV [[haloperidol]], which is approximately half as potent (~5-10mg [[haloperidol]] = ~2.5-5mg olanzapine)		*Consider IV [[olanzapine]] 2.5-5mg IV q5-10min to max dose of 20mg
	***May be safer in patients with prolonged QTc or those too agitated to obtain ECG		**In place of IV [[haloperidol]], which is approximately half as potent (~5-10mg [[haloperidol]] = ~2.5-5mg olanzapine)
	***IV [[olanzapine]] may be as safe or safer than IM, with faster onset		**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==		==Disposition==

Iaso at 08:53, 16 February 2017

2017-02-16T08:53:32Z

← Older revision		Revision as of 08:53, 16 February 2017
Line 1:		Line 1:
	==Background==		==Background==
	*Also known as agitated delirium		*Also known as agitated delirium
	*Controversial diagnosis, not recognized by DSM 4 or ICD 9		*Controversial diagnosis, not recognized by DSM 4/5 or ICD 9/10
	*Recognized by ACEP in 2009<ref name="ACEP">ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009</ref>		*Recognized by ACEP in 2009<ref name="ACEP">ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009</ref>
	*Agitation, aggression, acute distress, often in pre-hospital setting including police custody<ref name="WestJEM">Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83</ref>		*Agitation, aggression, acute distress, often in pre-hospital setting including police custody<ref name="WestJEM">Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83</ref>

Rossdonaldson1: Text replacement - " olanzapine " to " olanzapine "

2016-11-13T19:35:47Z

Text replacement - " olanzapine " to " olanzapine "

← Older revision		Revision as of 19:35, 13 November 2016
Line 36:		Line 36:
	***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

	==Disposition==		==Disposition==

Rossdonaldson1: Text replacement - " haloperidol" to " haloperidol"

2016-08-03T15:58:02Z

Text replacement - " haloperidol" to " haloperidol"

← Older revision		Revision as of 15:58, 3 August 2016
Line 32:		Line 32:
	*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
Line 46:		Line 46:
	==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==

Neil.m.young: Text replacement - "==Diagnosis==" to "==Evaluation=="

2016-07-22T00:37:01Z

Text replacement - "==Diagnosis==" to "==Evaluation=="

← Older revision		Revision as of 00:37, 22 July 2016
Line 17:		Line 17:
	*[[Hyperthermia]]		*[[Hyperthermia]]
	*[[Altered Mental Status (AMS)]]		*[[Altered Mental Status (AMS)]]
	==~~Diagnosis~~==		==Evaluation==
	*Typical clinical features associated with		*Typical clinical features associated with
	*Tachycardia		*Tachycardia

Neil.m.young: Text replacement - "5 mg" to "5mg"

2016-07-21T07:40:50Z

Text replacement - "5 mg" to "5mg"

← Older revision		Revision as of 07:40, 21 July 2016
Line 36:		Line 36:
	***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-~~5 mg~~ 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-~~5 mg~~ 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

← Older revision		Revision as of 16:08, 31 August 2022
Line 51:		Line 51:
	==See Also==		==See Also==
	*[[Altered mental status]]		*[[Altered mental status]]
			*[[Agitated or combative patient]]

	==References==		==References==