Excited delirium

Background

• Also known as agitated delirium
• Controversial diagnosis, not recognized by DSM 4 or ICD 9
• Recognized by ACEP in 2009
• Agitation, aggression, acute distress, often in pre-hospital setting including police custody
• Associate with hyperthermia, drug use and sometimes death

Clinical Features

• 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

• Neuroleptic Malignant Syndrome (NMS)
• Hyperthermia
• Altered Mental Status (AMS)

Diagnosis

• Typical clinical features associated with
• Tachycardia
• Tachypnea
• Hyperthermia
• Acidosis
• Rhabdomyolysis

Management

• Supportive care: reversal of clinical and lab abnormalities
  • Hyperthermia: Remove clothing, misting/airflow, ice packs , cold IV fluids
  • Acidosis: IV fluids; bicarb controversial
  • Rhabdomyolysis: IV fluids
  • Hyperkalemia
• Agitation: Physical and Chemical sedation
  • Benzodiazipines, Neuroleptics
  • Ketamine use increasingly described
    • 4-5mg/kg IM
    • 1-2mg/kg IV
  • Case reports using dantrolene

Disposition

• Based on severity of clinical presentation and response to treatment

See Also

http://lifeinthefastlane.com/crazy-then-dead/