HWN Suggests

The Seriousness of Deliriousness: Delirium in the ED

The fluctuating presentation of delirium makes it difficult to recognize but we should be attentive to certain hallmarks, including alterations in attention and awareness and acute changes in cognition. These can be associated with hallucinations or other perceptual disturbances. Collateral information and family input can be critical in detecting changes from baseline function and cognition. The more acute temporal course of delirium is important to distinguish from underlying dementia, which is itself one of the most important risk factors for delirium.

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 Excited Delirium: Understanding the Evolution Away from a Controversial Term

For decades, law enforcement officers, medical examiners and emergency medical professionals have used the terms “excited delirium” and “excited delirium syndrome” to describe subjects experiencing extreme agitation, excitability, paranoia and aggression, often associated with stimulant use and certain psychiatric disorders. While officers continue to encounter subjects displaying such symptoms, the term “excited delirium” has come under significant scrutiny and is now disavowed by major medical and psychological organizations...

 Excited delirium: valid clinical diagnosis or medicalized racism? Organized medicine needs to take a stand

The “diagnosis” of excited delirium, a term often used to justify and defend police brutality, disproportionately against Black people, has circulated in the medical canon for more than 25 years. It is time — past time, actually — for organized medicine to denounce its diagnostic validity and its use as a shield to justify excessive police force.

Articles of Interest

Episode 2: Excited Delirium

Excited Delirium Syndrome has recently been recognized by the American College of Emergency Physicians as a true medical emergency in which, typically, a young obese male, often under the influence of sympathomimetic drugs, becomes acutely delirious and displays super-human strength, tachypnea, profuse sweating and severe agitation. Usually, there is a prolonged and continued struggle with law enforcement despite physical restraints . Severe acidosis, rhabdomyolysis and hyperkalemia ensue, often leading to a sudden bradyasystolic cardiac arrest.

EMS Protocol of the Week - Excited Delirium

The Hennepin study, along with many other EMS systems, utilizes a 5mg/kg dosing strategy for IM ketamine; for context, Elijah McClain appears to have been given a good deal more. Our own protocol here in NYC calls for 2-4mg/kg IM. Of note, a more recent study by the same Hennepin group comparing prehospital ketamine to midazolam was suspended after public backlash over informed consent with regards to ketamine administration.

Excited Delirium

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.

Excited Delirium: Acute Management in the ED Setting

Excited delirium syndrome is a common yet poorly characterized ED presentation with a wide differential diagnosis. Patients are often identified initially by law enforcement, but attempts to control individuals experiencing ExDS via physical, chemical, or electrical restraints are associated with an exceedingly high rate of morbidity and mortality.

Excited Delirium: The ED Minefield

Excited delirium is easily identified in the Emergency Department (ED), but its cause is often illusive. Patients presenting with excited delirium are frequently those heard screaming down the hallway making the entire ED turn their attention to them as they get carted into a resuscitation bay for further management.

Ketamine an Ideal Treatment for Excited Delirium

The dose is 1.5-2 mg/kg if the drug can be given intravenously, and 5-6 mg/kg dose is standard intramuscularly. It's probably best to limit the first dose to 300 mg IV/600 mg IM. Those who have not used it before will be amazed by its rapid onset by the IM route.

Managing Delirium In The Emergency Department: Tools For Targeting Underlying Etiology

Delirium can be diagnosed using validated standardized screening tools such as the Confusion Assessment Method. Management of delirium is directed towards rapidly treating the underlying medical condition while preventing and managing the behavioral symptoms with nonpharmacological (first-line) and pharmacological (second-line) interventions.

Managing Delirium In The Emergency Department: Tools For Targeting Underlying Etiology

Ketamine is often used for procedural sedation in the ED and has also been used in the prehospital and hospital settings to manage severe undifferentiated agitation.103 Ketamine dosed at 1 to 2 mg/kg IV or 4 to 5 mg/kg IM may be used for acute agitation after traditional management has failed. The studies on ketamine use are limited to small samples, and neither dosing for acute agitation nor its use in delirium has been established in the literature to date.

SGEM#218: Excited Delirium Syndrome

A universally recognized definition is lacking, remaining mostly syndromic and based on clinical subjective criteria. High mortality rate may be due to definition inconsistency and reporting bias. Our results suggest that ExDS is a real clinical entity that still kills people and that has probably specific mechanisms and risk factors. No comparative study has been performed to conclude whether one treatment approach is preferable to another in the case of ExDS.”

The Evolution of Ketamine for Severe Agitation

While we do not recommend ketamine as a first line agent for the treatment of mild to moderate agitation, it does have a role in the treatment of the combative excited delirium patient. In patients for whom rapid sedation is imperative, consider giving at least 1 mg/kg IV or 5 mg/kg IM

Your patient may be delirious: What do you do next?

“I recommend extremely low doses “0.25 to 0.5 mg,” Dr. Rudolph says. “And if that gets them calm, you can switch to an atypical antipsychotic.” He adds that there is still a tendency, especially in the emergency department, to use far higher doses than necessary. When he’s prescribing risperidone, Dr. Rudolph recommends starting with 0.25 mg. When prescribing olanzapine, he suggests starting with 2.5 mg. With quetiapine, he recommends an initial dosing of 25 mg.

Resources

EMcrit Project

Nocturnal dexmedetomidine: May be excellent in patients with nocturnal agitation and circadian rhythm disruption. At night, titrate dexmedetomidine to achieve light sleep. Discontinue dexmedetomidine during the day, to maintain circadian rhythm. Alternative: If difficulty sleeping, consider scheduled pharmacologic therapy early in the night (e.g., quetiapine 25-50 mg qhs. Alternative: If difficulty sleeping, consider scheduled pharmacologic therapy early in the night (e.g., quetiapine 25-50 mg qhs ????).