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Mohammad Kadamany
PGY-4 KAMC Makkah
Points to cover
 Introduction
 Pathophysiology
 Presentation
 Diagnosis
 Management
 Disposition
Introduction
• What is delirium?
• Why it happens?
• Types of delirium
• Hypoactive
• Hyperactive
• Mixed
Excited Delirium Syndrome
 It’s a bizarre, aggressive behavior
 Shouting, paranoia, panic
 Accompanied with drug abuse
 Medical emergency
 Common in prehospital environment
How does it happen?
 It’s all about
CATECHOLAMINES!
How do they look?
 Males, 30s
 Psychiatric illness
 Nudity or inappropriate clothing
 Erratic/violent behavior
 Attraction to a reflective surfaces
How do they look?
 Tachypnea
 Tachycardia
 Hyperthermia
 Hypertension
 Resistant to restraint (Superhuman)
Workup
 CBC/cultures
 Blood glucose
 Renal functions
 VBG
 CK
 ECG
 Brain CT w/o contrast
Management
 Identify it ASAP/call for help
 De-escalating behavior
 Restrain? taser?
 Monitor, quiet environment
 Medications
 Supportive treatment
Physical restraints
• Indications
• Contraindications
• Preparation
• Technique
• Monitoring
• Side effects
• Documentation
• Removal
https://pubmed.ncbi.nlm.nih.gov/12609639/
Sedatives
 Lorazepam or midazolam
 Works on GABA rec
 Can be given IM, IV, IO
 Doses are higher than usual agitation
 Disadvantages
Antipsychotics
 Haloperidol (1st generation)
 Ziprasidone & olanzapine (2nd generation)
 Bind tightly to dopamine receptors
 Disadvantages
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483410/
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
Supportive Therapy
 Hyperthermia:
 Check temp periodically
 Follow the hospital protocol
 Metabolic acidosis
 IVF (crystalloids)
 NaHCO3 (3 amps in the 1 L D5W)
Disposition
 Acute intoxicated are dischargeable
 Admission for further workup and
management
 Patients die from:
 Respirator depression
 Acidosis
 Severe hyperthermia
www.exciteddelirium.com
https://www.emra.org/emresident/article/excited-delirium/
https://www.emra.org/emresident/article/excited-delirium/
https://www.emra.org/emresident/article/excited-delirium/
References
Excited delirium syndrome

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Excited delirium syndrome

Editor's Notes

  1. -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
  2. 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.
  3. The mech simply by consuming cocaine/PCP which blocks the dopamine re-uptake  dopamine accumulation  sympathomimetic effect.
  4. Like glass  has similar presentations for patients presenting with neuroleptic malignant syndrome
  5. BMP check for renal failure and hyperkalemia, EKG for dysrhythmia or prlonged QT synd, VBG for acidosis, CK for rhabdo
  6. 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)
  7. 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,
  8. 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%
  9.  - 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
  10.  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
  11. -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. 
  12. Age is imp (young better prognosis)
  13. This website is designed by Miami University