Podcast #102 - Pearls for Excited Delirium

Excited delirium has been covered quite a bit, but like other hot topics it is always changing with new evidence.  Here are some of the key pearls and pitfalls to managing this high risk population.

There are levels of agitation and how you manage them.  Reuben Strayer when at SMACC in Dublin, Ireland (#smaccDub) gave a very concise way of looking at how to manage such patients.  As the infographic (borrowed from CORE EM) demonstrates, there are doses of these medications to work with in managing these patients.  Simply, think of it as follows:

• Agitated but cooperative
  • "Green Zone" patients 
  • These people need kindness and compassion most of the time
  • Sometimes, oral medications can be used
  • If a little more significant, a bit of lorazepam (1-2mg) can be helpful
• Disruptive but not dangerous
  • "Yellow Zone" patients
  • With their loud outbursts, they can be redirectable to a degree but their disruptive nature needs additional management
  • Help them "sleep it off" with some haloperidol and midazolam (often 5-10mg of each)
  • Some will use the "B52 combination" 
    • Be more cautious of airway and respiratory issues though
    • Often 50mg of Benadryl (diphenhydramine), 5mg of Haldol (haloperidol), and 2mg of Ativan (lorazepam)
• Excited Delirium
  • "Red Zone" patients
  • These are dangerous patients who will not engage with you directly and are essentially incoherent meaning that "talking down" is ineffective
  • Medication of choice for the quickest and biggest bang for your buck is ketamine 500mg (or 4-6mg/kg but most patients will be fine with the empiric dose)
  • Usually, the trick is getting the patients down to get them medicine safely

To control a patient with excited delirium, you need to be ready to manage immediately:

• Assemble your team
  • Minimum of six people (one for each extremity, one for the head, one for medication delivery)
  • This is not a time to put it an IV (the dose of ketamine above is IM and this is safest)
  • Place an oxygen mask on the patient (delivers oxygen while stopping biting and spitting)
  • Additional personnel can help place physical restraints and to further hold
  • Remove dangerous restraints and positions as soon as possible
  • As  always, be prepared to manage the airway (you don't know what else is on board)
  • Intubation is NOT a failure
  • Get IV access once the patient is safely restrained and sedated
• Assess and monitor closely
  • Obtain vital signs and repeat frequently
  • Check a rectal or Foley temperature immediately
  • Do not forget about a finger stick glucose
  • Elevate head of be and have airway monitoring (such as ETCO2)
• Begin work up for underlying causes and check for life threats
  • Hyperpyrexia (extremely elevated temperatures) are often seen
  • Aggressively manage and fluid resuscitate (cold fluids if elevated temperature)
  • To evaluate for underlying or life threatening causes/complications check glucose, ABG, CBC, CMP, drug screen, CK, and head CT (include other CTs for other areas of trauma)
  • Always consider the potential for lumbar puncture
• Disposition these patients quickly
  • Once you have the work up completed, make sure to move these patients where they need to go for further management
  • They are very time and resource demanding requiring ICU level care

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