Dr. Margaret Thompson, Canada’s toxicology guru and Dr. Dan Cass review the clinical presentation, precipitating factors and important do’s and don’ts in managing patients with Excited Delirium Syndrome to prevent sudden death. They update us on the most current guidelines for Excited Delirium Syndrome and discuss the prevalent theories to explain why many of these patients have cardiac arrests.
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. Listen to this fascinating episode to find out how you can recognize and treat this important syndrome.
Dopamine hypothesis: Predisposition in certain individuals to deficiency of dopamine transport in the brain, and association with dopamine-altering psychotropic drugs
This cannot explain fully the pathophysiology, however, as drugs with no dopaminergic activity (PCP, amphetamines) are also involved in many cases of Excited Delirium Syndrome
Cocaine effects: Chronic cocaine use leads to dopamine depletion in striatum and therefore affects dopaminergic balance, and also leads to cardiac hypertrophy and contraction bands, potentially making the heart more susceptible to arrest
Positional or compression asphyxia
Probably negligible involvement of position in contribution of death in cases of excited delirium, although allowing patients to breathe effectively is obviously important
Differential diagnosis of Excited Delirium
Any diagnosis leading to altered mental status, especially the following:
Serotonin syndrome, sympathomimetic syndrome, neuroleptic malignant syndrome (NMS), psychotropic drug withdrawal or acute psychiatric condition, diabetic hypoglycemia, heat stroke, thyrotoxicosis
How to differentiate Excited Delirium Syndrome from sympathomimetic syndrome:
Often present similarly but more likely to display bizarre abnormal behavior (eg, walking through traffic, being naked in public), with non-toxic amount of recent drug use
Management of Excited Delirium – 3 spheres
Minimize use of and time spent in physical restraints, using as many properly trained people as possible for as short of a time as possible
Benzodiazepines: first-line due to their decrease in sympathomimetic outflow by central anxiolytic effects and potential cardioprotective effects (in animal studies); a single IM dose of benzodiazepine has never been reported to be fatal
Although neuroleptics and ketamine are other choices, they have more downsides: Dopaminergic interaction and QT prolongation in neuroleptics
Laryngospasm for IM ketamine, potentially worsening a difficult airway
Update 2015: For a review of the use of ketamine for excited delirium check out ALiEM.
IV fluids (at least 2L NS bolus, cooled if possible), which will also help in the treatment of rhabdomyolysis and acidosis
Aggressive cooling: cooled fluids, ice packs to groin and axilla, fans with mist spray, cooling blanket
Can be very severe (almost incompatible with life)
Consider 1-2 amp of sodium-bicarbonate IV empirically, which will also help the likely hyperkalemia
If RSI is performed, hyperventilate immediately as the respiratory drive that was blowing off the CO2 is now gone with paralysis (potentially worsening acidosis)
Future research and education
Generally accepted case definition needed for advances in understanding of condition
Education for law enforcement personnel, EMS, and EPs
Medical, not behavioral, issue that must be promptly recognized both out-of-hopistal and in-hospital, and aggressively treated
2009: White Paper Report by the American College of Emergency Physicians’ Excited Delirium Taskforce Full PDF
Other FOAMed Resources on Excited Delirium
Kane Gurthrie on Life in the Fast Lane reviews Excited Delirium
Dr. Helman, Dr. Thompson and Dr. Cass have no conflicts of interest to declare.
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.