Management of acute delirium and ARDs

1. Ask the Expert – Toxicology &
ARDS Interactive Cases
Dr. Badar Islam
Senior Emergency Medicine Resident
Shifa International Hospital,
Islamabad

2. Case 1: The Man Who Wouldn’t
Stop
• 22-year-old male brought tied with ropes after
violent and erratic behavior.
• Tried to grab a gun, drove at 150 km/h.
• Given IM diazepam and haloperidol before
arrival.

3. Interactive Question 1
• What is your first priority when such a patient
arrives?
• A) Get history
• B) Secure airway
• C) Ensure safety
• D) Start IV fluids
• ✅ Correct: C – Safety first.

4. ED Scene
• Patient intermittently shouting, then wakes up
extremely aggressive.
• Threatening staff, strong and violent.
• Doctor cornered with potential weapons
nearby.

5. Interactive Question 2
• What should the attending do?
• A) Try to reason calmly
• B) Back away and call for help
• C) Physically restrain
• D) Call security + sedate simultaneously
• ✅ Best: B + D

6. Chemical Restraint
• Options:
• A) Haloperidol + Lorazepam
• B) Midazolam alone
• C) Ketamine IM
• D) Dexmedetomidine IV
• ✅ Correct: C – Ketamine IM 4–5 mg/kg
• Rapid control for violent agitation.

7. Toxicology Findings
• UDS: only cannabis positive.
• Reason: Other substances may have short
detection windows.
• Synthetic drugs often undetectable.
• Rebound psychosis possible.

8. Post-Sedation Phase
• Airway protected, vitals stable.
• After 4 hours: calm, oriented, amnesic.
• Next step: Psychiatric evaluation for
substance-induced psychosis.

9. Key Takeaways – Toxicology
• 1. Safety first – protect team & patient.
• 2. Rapid sedation saves lives.
• 3. Negative tox screen ≠ negative intoxication.
• 4. Ketamine is effective for excited delirium.
• 5. Always involve psychiatry.

10. Case 2: Breathless in Seconds
• 28-year-old male, healthy, presents with
severe dyspnea.
• SpO₂ 68% on room air.
• Fever, cough for 5 days.
• Tachypneic and tachycardic.

11. Interactive Question 1
• First step?
• A) Antibiotics
• B) High-flow nasal cannula (HFNC)
• C) Intubate
• D) Chest X-ray
• ✅ Correct: B – Oxygen first.

12. Progress
• On HFNC FiO₂ 0.8 → SpO₂ 90%.
• CXR: Bilateral infiltrates.
• Diagnosis: ARDS likely.

13. Interactive Question 2
• SpO₂ drops to 82% despite HFNC.
• Next step?
• A) Increase FiO₂
• B) NIV
• C) Intubate
• D) Diuretics
• ✅ Correct: C – Intubate.

14. Ventilation Strategy
• Tidal volume 8 mL/kg → Pplat 38.
• SpO₂ 86%.
• Next step: Decrease tidal volume to 6 mL/kg.
• ✅ Gentle ventilation protects lungs.

15. Desaturation Challenge
• After 30 min: SpO₂ 84%, FiO₂ 1.0, PEEP 14, BP
85/50.
• Next step?
• A) Prone
• B) Fluids
• C) Vasopressors
• D) A + C
• ✅ Correct: D – Prone + vasopressors.

16. Outcome
• After 16 hours prone + low tidal volume:
• PaO₂/FiO₂: 70 → 180.
• Extubated day 6, discharged day 10.

17. Key Learning Pearls – ARDS
• 1. Recognize ARDS early.
• 2. Use low tidal volume ventilation.
• 3. Restrict fluids; support with vasopressors.
• 4. Prone early.
• 5. Oxygenate, protect, perfuse, prone.