Ver el código de «Excited delirium»

==Background==
*Also known as agitated delirium
*Controversial diagnosis, not recognized by DSM 4/5 or ICD 9/10
*Recognized by ACEP in 2009<ref name="ACEP">ACEP White Paper Report on Excited Delirium Syndrome. Sept 10, 2009</ref>
*Agitation, aggression, acute distress, often in pre-hospital setting including police custody<ref name="WestJEM">Takeuchi, A. Excited Delirium. West J Emergency Medicine; 2011 Feb; 12 (1): 77-83</ref>
*Associate with hyperthermia, drug use and sometimes death<ref name="WestJEM"/>
==Clinical Features<ref name="ACEP"/>==
*Triad of [[delirium]], psychomotor [[agitation]] and physiological excitation 
*Associated with drug use: [[cocaine]] (#1), [[methamphetamine]], [[alcohol]], [[PCP]], [[LSD]]
*Associated with mental health disease
*Typically male, mean age 30's
*Violent, combative, belligerent, bizarre behavior
*Resistant to physical restraint, superhuman strength
*Associated with cardiopulmonary arrest
==Differential Diagnosis==
*[[Neuroleptic Malignant Syndrome (NMS)]]
*[[Hyperthermia]]
*[[Altered Mental Status (AMS)]]
==Evaluation==
*Typical clinical features associated with
*[[Tachycardia]]
*[[Tachypnea]]
*[[Hyperthermia]]
*[[Acidosis]]
*[[Rhabdomyolysis]]
==Management==
===Supportive care===
*Evaluation for reversible clinical and lab abnormalities
*[[Hyperthermia]]: Remove clothing, misting/airflow, ice packs , cold IV fluids
*[[Metabolic Acidosis|Acidosis]]: IV fluids; bicarb controversial
*[[Rhabdomyolysis]]: IV fluids
*[[Hyperkalemia]]
===Agitation Reduction===
*Prioritize chemical sedation although some physical restraint is always required
*[[Benzodiazepines]], [[Neuroleptics]]
*[[Ketamine]] use increasingly described<ref>Roberts, J: Emergency Medicine News website. http://journals.lww.com/em-news/Fulltext/2015/12000/InFocus__Ketamine_an_Ideal_Treatment_for_Excited.18.aspx Unknown published date. Accessed Dec 13, 2015</ref> but may be related with increased side effects such as intubation when used at max IM dosing<ref>Cole JB, et al. A prospective study of ketamine versus [[haloperidol]] for severe prehospital agitation. Clin Toxicol. 2016 Apr 21. Epub ahead of print.</ref>
**4-5mg/kg IM
**1-2mg/kg IV
*Consider IV [[olanzapine]] 2.5-5mg IV q5-10min to max dose of 20mg
**In place of IV [[haloperidol]], which is approximately half as potent (~5-10mg [[haloperidol]] = ~2.5-5mg olanzapine)
**May be safer in patients with prolonged QTc or those too agitated to obtain ECG
**IV [[olanzapine]] may be as safe or safer than IM, with faster onset

==Disposition==
*Based on severity of clinical presentation and response to treatment

==External Links==
*[http://lifeinthefastlane.com/crazy-then-dead/ LITFL: Crazy….Then Dead!]
*[http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/ PulmCrit: Intravenous olanzapine: Faster than IM olanzapine, safer than IV [[haloperidol]]?]

==See Also==
*[[Altered mental status]]
*[[Agitated or combative patient]]

==References==
<references/>

[[Category:Psychiatry]][[Category:Toxicology]]