Excited delirium

Excited delirium
Other names: Excited delirium syndrome, agitated delirium
An example of physical restraints which may be used until chemical sedation takes effect.
Specialty	Emergency medicine, psychiatry
Symptoms	Agitation, delirium, sweating[1]
Complications	Rhabdomyolysis, high blood potassium[1]
Causes	Drug use, mental illness[1]
Differential diagnosis	Low blood sugar, heat stroke, thyrotoxicosis, paranoid schizophrenia, bipolar disorder[1]
Treatment	Sedation, cooling, intravenous fluids[1]
Medication	Ketamine or midazolam and haloperidol[2]
Prognosis	Risk of death < 10%[1]
Frequency	Unknown[1]

Excited delirium, also known as agitated delirium, is a condition that presents with psychomotor agitation, delirium, and sweating.^[1] It may include attempts at violence, unexpected strength, and very high body temperature.^[3] Complications may include muscle breakdown or high blood potassium.^[1]

The cause is often related to long term drug use or mental illness.^[1] Commonly involved drugs include cocaine, methamphetamine, or certain substituted cathinones.^[3] In those with mental illness, rapidly stopping medications such as antipsychotics may trigger the condition.^[1] The underlying mechanism is believed to involve dysfunction of the dopamine system in the brain.^[3] The diagnosis is recognized by the American College of Emergency Physicians but is not in the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases.^[1][4]

Treatment initially includes medications to sedate the person such as ketamine or midazolam and haloperidol injected into a muscle.^[2] Rapid cooling may be required in those with high body temperature.^[1] Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful.^[1] The risk of death among those affected is less than 10%.^[1] If death occurs it is typically sudden and cardiac in nature.^[1]

How frequently cases occur is unknown.^[1] Males are affected more often than females.^[5] Those who die from the condition are typically male with an average age of 36.^[1] Often law enforcement has used tasers or physical measures in these cases.^[1] A similar condition was described in the 1800s and was referred to as "Bell's mania".^[1] The term "excited delirium" did not come into use until the 1980s.^[1]

Signs and symptoms

The symptoms of excited delirium may include:^{[6][7][8][9][10]}

• Paranoia
• Disorientation
• Dissociation
• Hyper-aggression
• Fast heart rate
• Hallucination
• Sweating
• Incoherent speech or shouting
• Seemingly superhuman strength or endurance (typically while trying to resist restraint)
• High body temperature
• Inappropriately clothed e.g. having removed garments

Cause

Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV.^[11][12][13] Alcohol withdrawal or head trauma may also contribute to the condition.^[7] A majority of fatal cases involved men.

People with excited delirium commonly have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine.^[6] Other drugs that may contribute to death are antipsychotics.^[14][15][16]

Mechanisms

The pathophysiology of excited delirium is unclear,^[8] but likely involves multiple factors.^[17] These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal abnormal heart rhythms.^[17]

Diagnosis

Other medical conditions that can resemble excited delirium are panic attacks, hyperthermia, diabetes, head injury, delirium tremens, and hyperthyroidism.^[18]

Treatment

Two doses of intravenous ketamine, 100 mg/2 ml and 20 mg /2 ml

Treatment initially may include ketamine or midazolam and haloperidol injected into a muscle to sedate the person.^[2] Ketamine at a dose of 5 mg/kg IM or 1 mg/kg IV has a faster onset of benefits compared to the combination of midazolam and haloperidol.^[19][20]

Rapid cooling may be required in those with high body temperature.^[1] Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful.^[1]

History

In 1849 a similar condition was described by Luther Bell as "Bell's mania".^[21]

It was first described under the name "excited delirium" in 1985 as a condition relating to acute cocaine intoxication.^[7][22]

Controversy

See also

• Taser safety issues
• Positional asphyxia
• Sudden unexpected death syndrome
• Delirium tremens
• Stimulant psychosis

References