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20. Excited Delirium: “I’m So Excited … I Just Can’t Hide It”
Keywords
Excited DeliriumOveractive adrenergic autonomic dysfunctionMental statusAgitationCardiovascularTachycardicRegular rhythmCase
Pertinent History
A 23-year-old male presents via Emergency Medical Services (EMS), restrained and chemically sedated. He had been observed running through the streets naked and screaming, which prompted bystanders to call the local police department. Officers reportedly chased the patient through the neighborhood, and the pursuit ended when the patient ran through a glass storm door. At this point, several officers were able to wrestle the patient to the ground and EMS was able to rapidly sedate the patient. The patient required multiple doses of sedative medications before he could be safely transported to the emergency department (ED). Upon arrival to the ED, the patient is unresponsive to verbal stimuli presumably due to the sedatives used on scene.
Pertinent Physical Exam
BP 158/98, Pulse 132, and RR 32.
Except as noted below, the findings of the complete physical exam are within normal limits.
General: The patient is diaphoretic and unresponsive to verbal stimuli.
Cardiovascular: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs.
Skin: The upper chest and extremities are covered with multiple lacerations and abrasions of differing sizes.
Pertinent Test Results
The patient’s lab work revealed significant metabolic acidosis and a markedly elevated CK level.
Emergency Department Management
The patient required frequent large doses of benzodiazepines for continued sedation. He was intubated for airway protection. He was started on IV fluids for rehydration and a bicarbonate infusion to maintain a urine pH above or equal to 7.5. The patient’s lacerations were irrigated, sutured, and dressed. He was admitted to the Medical Intensive Care Unit for further management.
Learning Points: The Excited Delirium Syndrome
Priming Questions
- 1.
Describe the proposed pathophysiology of excited delirium.
- 2.
What diagnostic evaluation is required for this type of patient presentation?
- 3.
Why is it important to rapidly chemically restrain patient with suspected excited delirium syndrome? What are the preferred agents for chemical restraint?
- 4.
What additional medical management is indicated for these patients?
Introduction/Background
- 1.
The term “Excited Delirium” is a historically controversial subcategory of delirium, which describes a syndrome of altered mental status, agitation, and overactive adrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness [1].
For about 150 years, case reports have described cases with this constellation of symptoms without using the exact term “Excited Delirium,” which did not gain popularity until a 1985 paper by Wetli and Fishbain describing a series of cocaine-related deaths [1, 2].
Since 1985, the concept of Excited Delirium has been used by EMS, psychiatry, emergency medicine, and law enforcement to describe a subset of patients who are otherwise without a unifying clinical diagnosis. The term was developed to describe patients who suffered an apparent psychiatric decompensation, ultimately resulting in an unexplained death [1–3].
- 2.
The typical or classic course for an Excited Delirium patient begins with acute drug intoxication, often cocaine, a struggle with authorities or law enforcement, physical or chemical restraint, and sudden cardiac arrest [1, 3, 4].
Cases of death associated with Excited Delirium Syndrome tend to share similar features. Patients are overwhelmingly young adult males, with an average age of 36 years old. There is generally a history of drug use and aggressive or strange behavior prompting law enforcement involvement. Patients often have a history of psychiatric illness. Patients are frequently nude or dressed inappropriately for the situation or environment. They often fail to recognize or respond appropriately to law enforcement officers, and struggle against officers, staff, and providers. These patients are regularly noted to have “superhuman” strength and do not seem to fatigue [1, 5].
Physiology/Pathophysiology
- 1.
The pathophysiology of the Excited Delirium Syndrome remains unclear [1, 3, 6].
Illicit drug abuse, particularly cocaine, is highly associated with Excited Delirium Syndrome, though it does not appear that deaths can be attributed to simple drug overdose. Fatal cases of Excited Delirium have been found to involve serum cocaine concentrations similar to those found in recreational drug users rather than the high levels seen in acute fatal cocaine intoxication [1, 3].
- 2.
One hypothesized mechanism involves dopaminergic pathways in the central nervous system [6].
Postmortem brain examination of cocaine abusers who die in police custody has shown loss of dopamine transporters in the striatum, suggesting that excessive dopaminergic activation in the striatum may underlie Excited Delirium in these patients. These changes are likely induced by chronic psychostimulant use and may predispose the patient to an episode of Excited Delirium during episodes of acute-on-chronic drug abuse [1, 6].
Thermoregulation is also modulated by dopaminergic pathways, and dysregulation of these pathways may explain the hyperthermia commonly seen in Excited Delirium Syndrome [1].
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