Emergency Medicine is Hard

What does this look like?

Sudden onset of delirium with agitation (fear, panic, shouting, violence and hyperactivity), often associated with hyperthermia

What are the most common causes?

Majority of cases are precipitated by stimulant drug use and in much fewer cases psychiatric illness (such as mania, depression, or schizophrenia) or systemic illness

• Most common drugs include cocaine, methamphetamines, PCP and LSD
• Think dopamine excess leading to autonomic hyperactivity

What are the feared complications?

Respiratory arrest, cardiac dysrhythmia, DIC, rhabdomyolysis, renal failure, hyperthermia, metabolic acidosis, multisystem failure and/or death

Another potential cause of death is cardio toxicity due to chronic cocaine abuse. 

What are the priorities in management of excited delirium?

• Airway, Breathing Circulation is always a priority
• Cooling – External cooling, IVF
• Rapid sedation (to turn off the catecholamine cascade)
  • 5mg IM midazolam
    • One study of 111 violent and agitated patients compared efficacy and side effect profiles of intramuscular (IM) midazolam (5mg), lorazepam (2mg) and haloperidol (5mg) randomly assigned to the study participants. They concluded that midazolam had a significantly shorter onset (18.3 +/– 14 minutes) and more rapid time to arousal. 
  • 2mg IV lorazepam
  • 5mg haloperidol/droperidol
  • 2.5-5mg IV olazapine in patients with prolonged QTc

What about Ketamine for sedation?

Ketamine is often considered (because of its rapid onset, ability to maintain respiratory drive, and provide analgesia, and amnesia) in the pre-hospital setting because excited delirium victims do not have minutes to spare as they continue to struggle with law enforcement or physical restraints in a state of hyperthermia and metabolic acidosis

• IM dose: 4-5 mg/kg/dose (onset 3-4 minutes)
• IV dose: 1-2 mg/kg/dose (onset 30 seconds)

Don’t forget about Dantrolene

Excited delirium may present similarly to neuroleptic malignant syndrome, and malignant hyperthermia. Dantrolene could be considered as another helpful adjunctive therapy.

Dantrolene is a hydantoin derivative that abolishes excitation-contraction coupling of muscle cells by blocking calcium release from intracellular storage in the sacroplasmic reticulum.