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Excited delirium: Medical emergency – not willful resistance

The ability to think and act quickly when encountering a patient in an excited delirium situation could spell the difference between successful treatment and a lost life


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By Lorry Schoenly

Excited delirium, a condition characterized by extreme agitation, hyperactivity, and escalating body temperature, can turn a manageable spaced-out patient into the Incredible Hulk in a split second.

Excited delirium is not new and has been linked to many in-custody deaths; Now synthetic drugs like bath salts and flakka are being implicated in excited delirium situations as well.

A person with mental illness on one of these illicit drugs could make for a dangerous situation. The ability to think and act quickly in an excited delirium situation could spell the difference between successful treatment and a lost life. Here are the symptoms and treatments for this sometimes lethal condition.

Is this for real?

Although controversy still surrounds this condition, excited delirium is well-documented and continues to be studied by medical experts. The American College of Emergency Physicians affirmed the disorder in 2009. Their conclusion is that the condition needs further study, but is likely caused by stimulant drug abuse, psychiatric disease, psychiatric drug withdrawal or metabolic disorders. Somehow these conditions initiate a cascade of internal chemical processes that shift mental, physical and temperature regulation into overdrive. Experts stress the importance of law enforcement professionals being aware of and alert for the condition, and calling EMS.

What does excited delirium look like?

Unfortunately, excited delirium easily looks like willful resistance and extreme combativeness. That is why so many excited delirium in-custody deaths include the use of a Taser and other uses of force.

Hallmark signs of excited delirium include:

  • Extreme agitation – including fear, panic, shouting and violence
  • Delirium – hallucinations, disorientation, confusion
  • Hyperthermia – elevated body temperature, stripping off clothing to cool down
  • Superhuman strength – difficult to restrain and seemingly tireless

One suggested mnemonic to remember the signs of excited delirium is NOT A CRIME, created by emergency physician and EMS medical director Dr. Michael Curtis:

  • N: Patient is naked and sweating from hyperthermia
  • O: Patient exhibits violence against objects, especially glass
  • T: Patient is tough and unstoppable, with superhuman strength and insensitivity to pain
  • A: Onset is acute, witness say the patient “just snapped!”
  • C: Patient is confused regarding time, place, purpose and perception
  • R: Patient is resistant and won’t follow commands to desist
  • I: Patient’s speech is incoherent, often with loud shouting and bizarre content
  • M: Patient exhibits mental health conditions or makes you feel uncomfortable
  • E: EMS should request early backup and rapid transport to the ED

Fast action needed

Excited delirium is a medical emergency and needs medical attention as early as possible. This patient’s neurologic and metabolic systems have been supercharged. If the situation is not de-escalated quickly and the patient does not receive rapid medical intervention they may die of respiratory or cardiac arrest.

Chemical sedation is needed as quickly as possible to reduce the risk of impending death. Available medical personnel need to be called to the scene and a rapid sedation protocol initiated. While outside paramedics are on the way, intramuscular medication is needed to sedate the individual. Some success has been seen with sedatives and antipsychotics, but these take 10-15 minutes to start working.

Ketamine is a faster and more effective sedative for excited delirium. Intramuscular ketamine should be used as an anesthetic/sedative as soon as possible after the patient is physically restrained. Once sedated the patient needs transport to and close medical monitoring at the emergency department.

Best outcomes for excited delirium patients

Unfortunately, up to 250 people die as a result of excited delirium each year in the U.S.; an estimated 8-14 percent of those with the condition. Early detection and intervention can reduce this number.

Do you have an excited delirium protocol in place? Have you experienced a situation that might have been excited delirium? Share your tips and experiences in the comments section of this column.

About the author

Dr. Schoenly has been a nurse for 30 years and is currently specializing in correctional healthcare. She is an author and educator seeking to improve patient safety and professional nursing practice behind bars. Her web-presence, Correctional Nurse, provides information and support to those working in correctional health care. Her books, Essentials of Correctional Nursing and The Correctional Health Care Patient Safety Handbook are available in print and digital on Amazon.