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Excited Delirium

Aka: Excited Delirium, Agitated Delirium, Bell's Mania
  1. See Also
    1. Altered Level of Consciousness
    2. Violent Behavior
    3. Psychosis
  2. Epidemiology
    1. Male gender most common
    2. Mean age mid-30s
  3. History
    1. First described by Dr. Luther Bell in the 1800's (Bell's Mania)
      1. Described Excited Delirium in institutionalized patients
  4. Pathophysiology
    1. Triggered by stimulant drug use (Cocaine, Methamphetamine, PCP)
    2. May be related to excessive Dopamine stimulation in the striatum
  5. Associated Conditions
    1. Psychostimulant abuse (e.g. Cocaine, Methamphetamine)
    2. Mental Illness
  6. Precautions
    1. Excited Delirium patients are at high risk of injuring others
    2. 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)
  7. 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
      1. Delusional
      2. Paranoid or fearful
      3. Yelling, shouting or making guttural sounds
      4. Disrobes or wears inappropriate clothing
    5. Clinical signs
      1. Profuse diaphoresis
      2. Tachypnea
      3. Tachycardia
      4. Hyperthermia
      5. Hypertension
  8. Diagnostics
    1. Continuous cardiac monitor
    2. Electrocardiogram
  9. Labs
    1. Comprehensive Metabolic Panel
    2. Complete Blood Count
    3. Urinalysis
    4. Toxicology Screening
      1. Urine Drug Screen
      2. Blood Alcohol Level
      3. Acetaminophen Level
      4. Salicylate Level
    5. Creatinine Phosphokinase (CPK)
      1. Increased in Rhabdomyolysis
    6. Venous Blood Gas
      1. Metabolic Acidosis
  10. Differential Diagnosis: "Hot and Bothered Patient"
    1. See Sympathomimetic Toxicity
    2. See Altered Mental Status Differential Diagnosis
    3. See Violent Behavior
    4. See Psychosis
    5. Intracranial Hemorrhage (Acute Subdural Hematoma, Subarachnoid Hemorrhage)
    6. Diabetic Hypoglycemia
    7. Serotonin Syndrome
    8. Neuroleptic Malignant Syndrome
    9. Heat Stroke
    10. Alcohol Withdrawal
    11. Thyrotoxicosis
  11. 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
  12. Imaging
    1. Consider Head CT (and if trauma Cervical Spine CT)
  13. 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)
        1. Sedation
          1. Midazolam 2 mg IV, 5 mg IM or 5 mg intranasal (preferred Benzodiazepine for rapid onset) OR
          2. Ketamine 2 mg/kg IV or 5 mg/kg IM
        2. Other measures
          1. Normal Saline 500 to 1000 cc fluid bolus
          2. External cooling (Evaporative Cooling, cold packs)
        3. 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
  14. Management: Emergency Department
    1. Safely and quickly contain the patient
      1. See Physical Restraint
      2. 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. Rhabdomyolysis management as indicated
      2. Monitor for dysrhythmia
        1. Bradycardia may precede PEA or Asystole
  15. Resources
    1. ACEP White Paper: Excited Delirium
      1. http://www.fmhac.net/assets/documents/2012/presentations/krelsteinexciteddelirium.pdf
  16. References
    1. Takeuchi (2011) West J Emerg Med 12(1): 77–83 [PubMed]

Agitated delirium (C1848465)

Concepts Finding (T033)
English Agitated delirium
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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