EXCITED DELIRIUM

Individuals suffering from ED should be viewed as psychiatric patients and require immediate medical attention. ED is a medical emergency. 

Signs and Symptoms

Victims of excited delirium display sudden onset of paranoia and alternate between calm behavior and extreme agitation. When confronted by police, who are invariably called to the scene, the victim intensifies the violence and paranoia. An intense struggle ensues, when the victim exhibits incredible “superhuman” strength and is impervious to the usual police techniques of pain control, including pepper spray, peroneal baton strikes, and in certain cases, TASER deployment. The intense struggle requires the efforts of many police officers, who are finally able to restrain the victim and apply ankle and/or wrist restraints. Usually, within minutes of being restrained, the victim loses all vital signs. Core body temperatures average 105 degrees.  Resuscitation of these cases often results in a failed course of hospital treatment, characterized by a fatal sequence of rhabdomyolysis and renal failure.

Things to look for:

Treatments

Excited delirium is a medical emergency. Patients exhibiting signs of excited delirium require supportive care immediately:

- Sedation with benzodiazepines

- External cooling

- Intravenous fluids

- Maintain on cardiac and respiratory monitor

- ER treatment of rhabdomyolysis and hyperkalemia

What is Excited Delirium?

This disorder is usually drug-related (cocaine or “crack”, PCP or “angel dust”, methamphetamine, amphetamine), but can occur in non-drug users as well.

The presentation of excited delirium occurs with a sudden onset, with symptoms of bizarre and/or aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength, and hyperthermia. Hyperthermia is a harbinger of death in these cases.

Neurochemical systems in the brain are abnormal in this disorder. At the molecular level, excited delirium is characterized by dysregulated dopamine transporters (hyperdopaminergic state), elevated heat shock proteins (hyperthermia), and immediate early gene activation as a marker of paranoid aggression (c-fos protein). These molecular changes serve as biomarkers of the disorder.

While many factors are associated with sudden death in individuals requiring restraint for excited delirium, these individuals develop a disturbance in thought, behavior and mood, and become agitated and violent. This abnormal behavioral state is due to CNS mechanisms which are the cause of lethality. The brain controls the heart and respiration. Abnormal brain activity leads to the psychosis and sudden death.

Wetli suggests that there are three related syndromes: (1) acute exhaustive mania, as described by Bell in psychiatric patients, (2) excited delirium, due to psychostimulants (cocaine, methamphetamine, MDMA) and psychiatric illness; and (3) the attenuated variant - NMS (Wetli, 2005; Wetli and Natarjajan, 2005).

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