Excited delirium – a new syndrome?

With all the recent posts about sedation in Psych and agitation I thought I might take a moment to draw your attention to the recent White paper from ACEP about the syndrome that has come to be known as Excited Delirium.
This syndrome has been described in the literature for 150 years!  Only recently has there been an effort to formalise the symptoms into a treatable syndrome.  Some of the cases that have come up during the discussion could easity have been included under the desription of the syndrome – see Case 011 or the coroners report into Mr Fernandez in Qld 2005.
What are the basic features?
  • male subjects, average age 36
  • destructive or bizarre behavior generating calls to police,
  • suspected or known psychostimulant drug or alcohol intoxication,
  • suspected or known psychiatric illness
  • nudity or inappropriate clothing for the environment
  • Tachypnea, sweating, tactile hyperthermia
  • Pain intolerance – often struggle after Taser or pepper-spray
  • Obesity is a common finding in these cases
  • failure to recognize or respond to police presence at the scene (reflecting delirium),
  • erratic or violent behavior, often towards inanimate objects
  • unusual physical strength and stamina,
  • ongoing struggle despite futility,
  • cardiopulmonary collapse immediately following a struggle or very shortly after quiescence,
  • inability to be resuscitated at the scene, and
  • inability for a pathologist to determine a specific organic cause of death,
So is this a true “disease” or just the end point we see when patients on a catecholamine surge develop hypoxia and crash with severe acidosis?  This is the point of a lot of debate – some say it is the Taser that kills them, others the Police restraints, who knows.
What we do know is that these patients have an ominous tendency to crash and arrest almost without warning just seconds after “giving up the struggle”.  A brief period of quiescence followed by cardiopumonary arrest has been well described throughout the literature.
So how will this change my practice?  Well I think I ahve already stated my preference for doing sedation in a well controlled / airway ready environment.  I reckon this syndrome will make this conviction even stronger.  Beware the speeding/agitated patient who has just wrestled his way into the ED in Police custody – the urge to sedate is  strong… but just be ready to do a full ABC resus before you jab in some IM sedation!
    Has anyone out there seen something that meets this description?  Please share..
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