4. Introduction
• What is delirium?
• Why it happens?
• Types of delirium
• Hypoactive
• Hyperactive
• Mixed
5. Excited Delirium Syndrome
It’s a bizarre, aggressive behavior
Shouting, paranoia, panic
Accompanied with drug abuse
Medical emergency
Common in prehospital environment
6. How does it happen?
It’s all about
CATECHOLAMINES!
7. How do they look?
Males, 30s
Psychiatric illness
Nudity or inappropriate clothing
Erratic/violent behavior
Attraction to a reflective surfaces
8. How do they look?
Tachypnea
Tachycardia
Hyperthermia
Hypertension
Resistant to restraint (Superhuman)
16. Dissociative Agents
Ketamine is the most common
Given either IV 0r IM
Rapid onset
Preservation of airway reflexes
Wide safety margin
Disadvantages
https://www.jem-journal.com/article/S0736-4679(15)00147-X/fulltext
17.
18.
19. Supportive Therapy
Hyperthermia:
Check temp periodically
Follow the hospital protocol
Metabolic acidosis
IVF (crystalloids)
NaHCO3 (3 amps in the 1 L D5W)
20. Disposition
Acute intoxicated are dischargeable
Admission for further workup and
management
Patients die from:
Respirator depression
Acidosis
Severe hyperthermia
-Its fluctuation of the mental status (awareness and inattention) over a short time
-Its due acute systemic or CNS stressor
-Hypoactive, hyperactive or mixed
-Drugs intoxication which occurs mainly in young pt is our talk
individual totally out of control, unable to be reasoned or talked down
one of the greatest challenges you can face, and will challenge everyone involved, from the nurses and doctors ,to the police and security staff trying to physically restrain them.
About 250 people die in the United States each year.
The mech simply by consuming cocaine/PCP which blocks the dopamine re-uptake dopamine accumulation sympathomimetic effect.
Like glass
has similar presentations for patients presenting with neuroleptic malignant syndrome
BMP check for renal failure and hyperkalemia,
EKG for dysrhythmia or prlonged QT synd,
VBG for acidosis,
CK for rhabdo
Identification is the main goal of therapy, you need at least 6 people
Put him/her on a stretcher can be seen by ED staff to avoid self-harm
Some studies said taser actually ineffective and some studies said restrain is worse (more acidosis)
GABA is the main inhibitory of the brain
Alternative route IN midazolam
Higher than usual (therapeutic window is wide so be careful not to reach the toxic dose “resp depression”) 2 mg lora is accepted
Disadv: slow action if given IM, resp depression, synergism w/ ETOH, hypotension,
Typical ones bind dopa with little activity at other receptor sub-types (alph, beta,..) avoid excessive dopa,
Haldol dose 5 mg is acceptable
Disa prolonged QT “torsade”, hyperthermia (neuroleptic malig synd) which are mainly by 1st gen.
Akathesia reported 8-30% and dystonia <10%
- safe use in the ED setting, particularly for procedural sedation or as an induction agent for intubation, particularly in asthma patients.
- 1-2 mg/kg or 4-5 mg/kg
can cause/worsen pre-existing hypertension and tachycardia,
case reports have indicated excellent clinical results and overall reductions in hyperadrenergic vital signs, presumably due to dissociative sedation
This study was a prospective, single-institution, randomized, open-label, real world, standard of care pilot study. Adult patients with combative agitation were randomized to ketamine (4 mg/kg IM or 1 mg/kg IV) or haloperidol/lorazepam (haloperidol 5-10 mg IM or IV + lorazepam 1-2 mg IM or IV). The primary outcome was sedation within 5 min, and secondary outcomes included sedation within 15 min, time to sedation, and safety
-By administering IVF, spraying, icepacks (axilla, neck, groin), ice-bath immersion
-Many EMS medical directors have adopted the practice of adding 3 amps (40–80 Meqs) sodium bicarbonate to the first 1 L D5W to hasten the reversal of metabolic acidosis, rhabdo and lower potentially life-threatening levels of potassium.
