Excited Delirium

[docB]

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I've recently had to read up on this again. I continue to think this isn't really a discrete clinical entity. I think it's simply the severe end of the sympathomemetic abuse and mania spectra.

Do you guys buy it as a distinct clinical entity?

Disclosure: I don't believe in fibromyalgia either.

Poll is public since this is a collegial discussion.

 

[The White Coat Investor]

I've recently had to read up on this again. I continue to think this isn't really a discrete clinical entity. I think it's simply the severe end of the sympathomemetic abuse and mania spectra.

Do you guys buy it as a distinct clinical entity?

Disclosure: I don't believe in fibromyalgia either.

Poll is public since this is a collegial discussion.

What do you mean excited delirium? You mean hopped up on meth? I agree it isn't a distinct entity.

 

[WilcoWorld]

Excited delirium is distinct from plain ol' delirium and (of course) from dementia. My differential Dx is different for excited delirium than for non-excited delirium. So, I answered yes, but maybe I misunderstood your question?

 

[dotcb]

I like the term "severely sympathetic"...

 

[docB]

Excited Delerium as a distinct clinical entity has been growing as an issue over the last decade. It is a hot topic for education and training particularly in law enforcement and EMS. I'm up to my eyeballs with it because of my EMS work. I sort of assumed it was widely known as a topic.

Here are some informational resources:

http://www.exciteddelirium.org

Wikipedia - Excited Delerium (I know. Wikipedia. But this is a good, quick summary.

In any case the idea is that patients who are severely agitated, often due to sympathomemitics and/or mania are at risk from a distinct clinical entity called Excited Delirium. They can suffer dangerous, even fatal, surges in catacholamines during this fragile state. Physical struggles with law enforcement or EMS or hospital staff during this time can exacerbate the clinical situation.

 

[docB]

Excited delirium is distinct from plain ol' delirium and (of course) from dementia. My differential Dx is different for excited delirium than for non-excited delirium. So, I answered yes, but maybe I misunderstood your question?

My thing with this is that there seems to be a big push to say that there is a big distinction between your run of the mill agitated meth head and these "Excited Delirium" patients. I don't think that there is. I think they're just degrees of severity on a spectrum.

 

[Daiphon]

My thing with this is that there seems to be a big push to say that there is a big distinction between your run of the mill agitated meth head and these "Excited Delirium" patients. I don't think that there is. I think they're just degrees of severity on a spectrum.

I didn't vote above, because I think the answer is both Yes and No.

To docB's point - yes, this does fall on a spectrum of severe sympathomimesis from stimulant agents. From a clinical standpoint, the manifestations are consistent with what one would expect from intoxication by these drugs. So, in this regard, I believe that you're correct in asserting "No."

However, to Wilco's point - what defines ExDS is the specific physiological changes that are occurring in these patients. Their risk of death due to their underlying intoxication, especially when looked at through the lens of what is required to protect them from themselves (e.g. immobilization), is much higher than that of your run-of-the-mill meth head. I mean, think of it this way - if they're already hyperstimulated, then why don't benzos work well? We give ketamine for ExDS - as a structural analog of PCP, it should be stimulating in its own right, but (with limited data) seems to work out well.

There was a presentation on this by the Regions Tox Group at the most recent NACCT in Atlanta a few weeks ago, and their data seemed to suggest better outcomes with ketamine instead of other pharmacologic agents.

One analogy (albeit not great, but it's the first thing that comes to mind) is Sudden Sniffing Death Syndrome - VF induced by inhalants and a sudden catecholamine surge (usually when mom or dad catches you huffing). It falls within the spectrum of VF, true; but due to the specific underlying pathophysiology instead of standard ACLS you want to give these patients beta-blockers in lieu of epi/amio/etc. While the VF will certainly kill the patient, it's a question of *what* is inducing VF... similar to the question of "super-high" vs. ExDS.

All this being said, I agree that more research needs to be done on this to tease out your exact question.

Cheers!
-d

 

[WilcoWorld]

Now I have a better handle on your question, thanks.

In light of making disposition decisions for EMS and Police, the term excited delirium is less helpful than some objective, observable findings would be. These could include:
1- Hyperthermia.
2- Persisting in attempts to resist restraint in spite of painful self-harm.

If they're doing either of these two things, they should probably be seen in an ED. The tweakers that satisfy themselves with pacing and shouting expletives after being cuffed by "Tiny", but who otherwise aren't harming themselves...they can stay in the LVPD's lock-up.

 

[Apollyon]

The tweakers that satisfy themselves with pacing and shouting expletives after being cuffed by "Tiny", but who otherwise aren't harming themselves...they can stay in the LVPD's lock-up.

Do you mean the LVMPD, or some other locale with similar initials?

 

[Arcan57]

I feel like it's a distinct entity, but also one that's difficult to recognize except in hindsight. One of the new popular local causes is something called 25i, which is an LSD analogue with significant sympathomimetic effects. It sucks to deal with and we've already had one fatality.

 

[WilcoWorld]

Do you mean the LVMPD, or some other locale with similar initials?

I stand corrected...that's what I get for trying to be cute.

 

[Apollyon]

I stand corrected...that's what I get for trying to be cute.

I'm just being a goof. It was in my mind because I recently saw the website while looking for the Fire Department (LVFR); I was going to write a guy a recommendation letter for the FD. It's a good thing I didn't, as the guy got arrested for diverting from the ambulance right around that time!