Behavioral Emergency/Hyperactive Delirium Management

Algorithm Steps

1. ▶

   Start

   Severe Behavioral Emergency

   Patient with extreme agitation +/- altered consciousness

   1. ⚠

      Warning

      ⚠️ Recognize Warning Signs

      Hyperactive delirium with agitation - medical emergency

      • Extreme agitation/combativeness
      • Hyperthermia (may exceed 40°C)
      • Diaphoresis
      • Altered consciousness
      • Tachycardia, hypertension
      • Unusual strength/endurance
      • May be associated with: stimulants, PCP, alcohol withdrawal, anticholinergics
      1. ●

         Action

         Scene Safety & Team Approach

         Protect patient and staff

         • Multiple trained personnel (5+ recommended)
         • Clear exit routes
         • Remove weapons/dangerous objects
         • Security presence
         • Prepare for chemical restraint
         1. ●

            Action

            Attempt Verbal De-escalation

            Brief attempt if safe

            • May not be possible in true hyperactive delirium
            • Speak calmly, identify yourself
            • Offer water, remove stimuli
            • If no response within 1-2 minutes, proceed to sedation
            1. ◆

               Decision

               Chemical Sedation Needed?

               If de-escalation fails or patient danger imminent

               1. ●

                  Action

                  Rapid Tranquilization

                  For severe cases

                  • KETAMINE 4-5mg/kg IM (fastest onset, 2-5 min)
                  • - Preferred for severe agitation
                  • - Requires airway monitoring post-sedation
                  • OR DROPERIDOL 5-10mg IM (if available)
                  • OR MIDAZOLAM 5-10mg IM + HALOPERIDOL 5-10mg IM
                  • May need multiple doses
                  1. ⚠

                     Warning

                     ⚠️ Physical Restraint Considerations

                     If needed, minimize duration

                     • NEVER leave in PRONE position
                     • Supine or lateral recovery position
                     • Continuous monitoring of airway
                     • Release as soon as sedation effective
                     • Document restraint every 15 min
                     1. ⚠

                        Warning

                        ⚠️ Manage Hyperthermia Urgently

                        Life-threatening if untreated

                        • Remove clothing
                        • Ice packs to axillae, groin, neck
                        • Cooling blankets
                        • Cold IV fluids
                        • Target temperature <38.5°C
                        • Antipyretics NOT effective (drug-induced hyperthermia)
                        1. ●

                           Action

                           IV Access & Resuscitation

                           After sedation achieved

                           • Aggressive IV fluid resuscitation
                           • Point-of-care glucose
                           • Labs: BMP, CK, lactate, VBG, toxicology
                           • ECG (stimulants cause arrhythmias)
                           • Continuous cardiac monitoring
                           1. ●

                              Action

                              Monitor for Complications

                              Life-threatening sequelae

                              • Rhabdomyolysis (CK often >10,000)
                              • Acute kidney injury
                              • Metabolic acidosis
                              • DIC
                              • Cardiac arrhythmias
                              • Aspiration
                              • Sudden cardiac arrest (risk in first hour)
                              1. ●

                                 Action

                                 Delirium Workup

                                 After stabilization, identify cause

                                 • Comprehensive toxicology
                                 • Stimulant screen (amphetamines, cocaine, cathinones)
                                 • Alcohol/drug withdrawal assessment
                                 • Infection screen (LP if indicated)
                                 • CT head if trauma or focal neuro signs
                                 • Metabolic workup
                                 1. ◆

                                    Decision

                                    Disposition

                                    Based on etiology and stability

                                    1. ●

                                       Action

                                       ICU Admission

                                       For unstable patients

                                       • Ongoing hyperthermia
                                       • Rhabdomyolysis requiring aggressive fluids
                                       • Cardiac arrhythmias
                                       • Respiratory compromise
                                       • Renal failure
                                    2. ✓

                                       Outcome

                                       Medical Clearance → Psychiatry

                                       If medically stable and psychiatric etiology

                                       • Complete medical clearance
                                       • Psychiatric evaluation
                                       • Substance use treatment if applicable
                                       • Safety assessment before transfer