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October 2020

Case Summary: Walking a Tightrope – Intoxication and Agitated Delirium

This case featured an individual who was found by police, in a car parked in an area of town frequented for street-level drug sales and use, and when they came upon his parked car he was bent over and insufflating a white powder off a tin and there was a beer bottle in the glass holder of the car.  The patient appeared to swallow some wrapped packets as police approached the vehicle.  The patient admitted to using cocaine and drinking some beer when brought to the ED, but he denied swallowing any packets.  He was refusing any care and reported that his signs/symptoms were because “I sniffed some lines of good cocaine!” He had initial tachycardia, mydriasis, was mildly diaphoretic however these symptoms were improving over the first 1-2 hours in the ED.  After an XR was obtained and showed an opacity in his GI track, the patient again denied ingesting anything and refused any care.  Shortly after this, about 90 minutes into his ED stay, he became abruptly agitated, tachycardic, severely diaphoretic, and had stiffened gripping the hospital gurney and was not able to follow commands.  Ultimately IM midazolam was given, an IV was subsequently placed, and the patient intubated with propofol used for sedation.  Core temperature monitoring via foley catheter and IVF administration was performed.  The patient had an initial fever that markedly improved with sedation.  An NG tube was placed with the administration of charcoal and golytely.

This case featured a discussion of drug-induced agitated delirium with experts dissecting the mechanism and common course of events that occur in the most severe type of agitated delirium, often referred to as Excited Delirium Syndrome (EDS). Discussion focused on myths and misperceptions related to the use of various terms when describing Excited Delirium Syndrome and pitfalls in the care of patients with agitation and delirium. Experts dissected the pharmacology and physiology of agitated delirium and discussed appropriate treatments and monitoring for such patients including when to sedation, types of sedation, hemodynamic and temperature monitoring, and cooling in these patients. Case discussion also included an overview of causes of agitated delirium, including drug-induced as well as non-pharmacologic mechanisms.

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References

Full Case Discussion can be found here: https://youtu.be/hICWUrWlKTA 

  1. Vilke GM, DeBard ML, Chan TC, Ho JD, Dawes DM, Hall C, et al. "Excited Delirium Syndrome (ExDS): defining based on a review of the literature". The Journal of Emergency Medicine. 43 (5): 897–905. doi:1016/j.jemermed.2011.02.017 Nov. 2012.
  2. American College Medical Toxicologist Board of Directors. “ACMT Statement on Ketamine Sedation and Law Enforcement.” 28 Sept. 2020: https://www.acmt.net/cgi/page.cgi/_zine.html/The_ACMT_Connection/Statement_on_Ketamine_Sedation_and_Law_Enforcement
  3. Vilke GM, Bozeman WP, Dawes DM, Demers G, Wilson MP. Excited delirium syndrome (ExDS): treatment options and considerations. J Forensic Leg Med. 2012 Apr;19(3):117-21. doi: 10.1016/j.jflm.2011.12.009. Epub 2012 Jan 25. PMID: 22390995.
  4. Mankowitz SL, Regenberg P, Kaldan J, Cole JB. “Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis.” J Emergency Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PMID: 30197153.