Excited delirium, now more often called hyperactive delirium with severe agitation, is a state of extreme agitation, confusion and high body temperature, often linked to stimulant drugs or psychiatric illness. These patients can suddenly go into cardiac arrest, so it is treated as a medical emergency, not only a behavioral one.
Key symptoms
- Extreme agitation, shouting and violent or bizarre behavior
- Confusion and paranoia
- Feeling very hot, sweating heavily or removing clothes
- Unusual strength and not responding to pain
- Recent cocaine, methamphetamine or other stimulant use
What you find on exam
- Scene safety first; get police help if needed
- High temperature, fast heart rate and fast breathing
- Hot, sweaty skin and large pupils
- Blood glucose and signs of injury or head trauma
- Watch breathing and responsiveness closely after any restraint or sedation
Tests
- Blood glucose at once
- Temperature, oxygen saturation and waveform capnography
- Cardiac monitor and 12-lead ECG
- In the hospital: CK, potassium, kidney function and toxicology
Treatment basics
- Verbal de-escalation and a calm, low-stimulus environment
- Physical restraint only as needed, never prone, never pressure on chest or neck
- Rapid sedation per protocol with ketamine, midazolam or droperidol
- Active cooling and IV fluids
- Continuous monitoring and rapid transport, ready for airway support and cardiac arrest
Red flags
- Sudden quiet or stop of struggling (may precede cardiac arrest)
- Temperature above 40 C (104 F)
- Slow or absent breathing after sedation or restraint
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; National EMS Education Standards (2021); NREMT psychomotor skill sheets (EMT and Paramedic). Written by Making Synapses. Making Synapses is not affiliated with these organizations.