Pertinent physical findings showed confusion and disorientation. Neurologic exam demonstrated a tonic-clonic seizure however a formal exam was not able to be performed. His core temperature was 103.5 rectally. Otherwise his exam was unremarkable.
The patient was resuscitated from his cardiac arrest, and then cooled. A head CT was performed which was unremarkable. He was admitted to the MICU. Although we do not know the diagnosis in the differential we must include an ingestion of a sympathomimetic substance such as Bath salts, environmental hyperthermia, febrile illness, status epilepticus. It seems as if the sympathomimetic substance that is a possible ingestion could have caused what appeared to be an excited delirium.
Article- Takeuchi Asia, Ahern Terence, Henderson Sean. Excited Delirium. Western Journal of Emergency Medicine. 2011;12(1): 77-83.
– Treatment of choice is neuroleptics and benzos. in one study midzolam had the shortest time to onset.
– another study found that using 2 drugs together was the most effective.
– if benzos are not enough to control use IM ketamine at 4mg/kg.
– Expand your differential diagnosis when you really don’t know what’s going on.
– Recognize that confused and agitated patients can have multiple possible causes for their symptoms. A hyperthermic patient who is believed to have either an excited delirium or an environmental hyperthermia should be cooled to a temperature below 103.
– Drugs that cause hyperthermia usually include:
Sympathomimetic agents or other central nervous system stimulants. Amphetamines (and their many derivatives), MDMA, Cocaine, PCP and others.
Anticholinergics such as atropine and related substances. Red as a beat, dry as a bone, hot as a hare, mad as a hatter, blind as a stone, and tacky as a leisure suit.
Selective serotonin reuptake inhibitors and related drugs producing a serotonin syndrome.