agitated delirium

Question 1

what is the first thing to asess for if a person is agitated and delirious

Answer 1

Assess the patient for a reversible cause such as hypoglycaemia or hypoxia, provided this can be done safely. Move to the appropriate section if a clear cause is found.

Question 2

step one in mild to moderate cases

Answer 2

• Attempt verbal de-escalation and move sequentially through the steps below if the level of agitation continues to pose a risk to safety.
• Consider calling for police assistance.
• Provide safe restraint if required.
• Gain IV access if feasible and safe.

Question 3

first drug used in mild to moderate

Answer 3

Administer olanzapine provided agitated delirium is not due to poisoning with an antipsychotic medicine, and the patient will take an oral medicine:
a) 10 mg of olanzapine PO. Reduce the dose to 5 mg if the patient is frail.
b) The dose may be repeated once after 20 minutes.

Question 4

next step if olanzapine is ineffective

Answer 4

Administer droperidol if olanzapine is not administered or is ineffective:
a) 10 mg of droperidol IM/IV. Reduce the dose to 5 mg if the patient is frail.
b) The dose may be repeated once after 20 minutes.

Question 5

if droperidol is unavailable or is ineffective in mild to moderate administer:

Answer 5

• Administer midazolam if droperidol is unavailable or is ineffective:
  a) 2-3 mg of midazolam IV every five minutes as required. Reduce the dose to 1-2 mg if the patient is frail, or
  b) 10 mg of midazolam IM. Reduce the dose to 5 mg if the patient is frail.
  c) The IM dose may be repeated once after 20 minutes.

Question 6

medication for severe and immediate life threat

Answer 6

Administer ketamine:
a) 1 mg/kg of ketamine IV (up to a maximum of 100 mg) every five minutes as required, or
b) 400 mg of ketamine IM if the patient weighs greater than 80 kg, or
c) 200 mg of ketamine IM if the patient weighs 80 kg or less.
d) The IM dose may be repeated once after 20 minutes.

Question 7

To have agitation the patient must have

Answer 7

an abnormal increase in motor activity. For example: trying to climb off the stretcher or actively resisting assessment, treatment and/or transport. Anxiety and/or signs of mental distress alone are not enough to define the patient as being agitated.

Question 8

To have delirium the patient must have

Answer 8

signs of an abnormal state of mind. For example: confusion, delusions or significantly abnormal behaviour.

Question 9

Agitated delirium may be caused by

Answer 9

drugs, infection, metabolic disorders (such as hypoglycaemia and hyponatraemia), liver failure, mental health disorders, dementia and drug withdrawal (particularly alcohol). In New Zealand the most common cause is recreational drug ingestion, particularly methamphetamines, cathinones and synthetic cannabinoids.

Question 10

When administering ketamine: key points

Answer 10

ū Ketamine should not be administered to patients with dementia unless all other options have been exhausted.
ū The goal is to produce a state of dissociation so that the patient can be safely restrained, and IV access obtained.
ū IV access should be obtained whenever possible and IV midazolam administered as the ketamine effect wears off, with the aim of transporting the patient in a sedated state.
ū If IV access cannot be obtained, IM midazolam should be administered using the doses described under mild to moderate risk to safety, in anticipation of the ketamine effect wearing off.

Question 11

Draw up of Midaz

Answer 11

Draw up 12mls saline in 20mls syringe, then 3ml of midaz, so there is 15 in 15
OR
8mls saline 2ml midaz