Emergency Management of Hyperactive Delirium and Severe Agitation

Educational Objectives

The goal of this program is to improve emergency management of hyperactive delirium. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate ketamine use in the prehospital setting in the management of hyperactive delirium.
2. Recommend appropriate medications for pharmacologic management of hyperactive delirium.

Summary

Report on emergency management of hyperactive delirium (HD): published in 2021 by the American College of Emergency Physicians (ACEP) task force; patient safety is the primary focus, and rapid restoration of normal physiology is the goal; verbal de-escalation techniques should be the first line of management; parenteral medications are often required to treat severe agitation

Epidemiology and terminology: data on mortality rate is not reliable; use of the term “excited delirium” is discouraged (often a postmortem diagnosis; controversial); the term “hyperactive delirium” is preferred, as it describes the patient’s mental status and neuromuscular activity and is a recognized medical term

Spectrum of acute brain dysfunction: 3 subtypes of delirium include hyperactive, hypoactive, and mixed; the Richmond Agitation-Sedation Scale is often used (HD corresponds to a score of +4)

Ketamine use in the prehospital setting: according to a position statement by the Joint American Society of Anesthesiologists/ACEP, ketamine may be used in an appropriate setting with monitoring and medical control for patient treatment, but use is opposed at the direction of law enforcement; Kupas et al (2021) suggested verbal de-escalation, minimizing physical restraints, and judicious use of ketamine or other parental medications to control agitation; Fernandez et al (2021) evaluated out-of-hospital administrations of ketamine, including those administered for altered mental status, and found that the mortality rate was low

De-escalation: should be tried first with the assistance of a crisis intervention team, if available; many departments have undergone specialized training to improve verbal de-escalation and minimize physical restraint

Pharmacologic management: irrespective of the cause, initial management remains the same; establishing intravenous access may be difficult in these patients, and oral medications may not be an option; intramuscular (IM) route is preferred

Ketamine: considered a great prehospital drug for the management of severe agitation, with no risk for respiratory depression or hypotension; demonstrated harms include prolongation of QT interval (minor; no significant association with Torsades de Pointes), hypertensive crisis, hypersalivation (can obstruct the airway), laryngospasm, and respiratory depression (may be less with IM administration); the recommended and commonly used dose is 4 mg/kg; a lower dose may be safer and effective, but unproven

Benzodiazepines: the preferred agent is midazolam in the emergency medical services setting (shorter time to adequate sedation); lorazepam is another option, but onset and duration of sedation are longer; risks of midazolam include respiratory depression (similar to ketamine [less with IM route])

First-generation antipsychotics: droperidol may be preferred as it has shorter onset and duration of action compared with haloperidol, which is also a reasonable option; QT prolongation is very uncommon

Second-generation antipsychotics: olanzapine is preferred; QT prolongation is not seen

Combination therapy: data show that combination of midazolam plus droperidol is not superior to single agent; increased rates of respiratory depression with the addition of midazolam is a concern; combination therapy may not be the preferred first-line therapy

Readings

Fernandez AR, Bourn SS, Crowe RP, et al. Out-of-hospital ketamine: indications for use, patient outcomes, and associated mortality. Ann Emerg Med. 2021;78(1):123-131. doi:10.1016/j.annemergmed.2021.02.020; Gottlieb M, Long B, Koyfman A. Approach to the agitated emergency department patient. J Emerg Med. 2018;54(4):447-457. doi:10.1016/j.jemermed.2017.12.049; Klein LR, Driver BE, Horton G, et al. Rescue sedation when treating acute agitation in the emergency department with intramuscular antipsychotics. J Emerg Med. 2019;56(5):484-490. doi:10.1016/j.jemermed.2018.12.036; Kupas DF, Wydro GC, Tan DK, et al. Clinical care and restraint of agitated or combative patients by emergency medical services practitioners. Prehosp Emerg Care. 2021;25(5):721-723. doi:10.1080/10903127.2021.1917736.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Hatten's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Hatten was recorded at the 13th Annual National Update on Behavioral Emergencies, held December 8-9, 2022, in Scottsdale, AZ, and presented by the American Association for Emergency Psychiatry. For more information about upcoming CME activities from this presenter, please visit emergencypsychiatry.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

PS520402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.