Adult Protocols: Agitated Patient and Excited Delirium Syndrome

Managing the Agitated Patient / Excited Delirium Syndrome

• Use the least restrictive method of restraint, prioritizing provider safety and allowing the patient to correct their behavior if possible.
• Restraints should be used as a last resort, only when the patient remains a threat to themselves or others, and in a supine or recovery position.
• Avoid placing the patient prone face down.

Chemical Restraint

• Ketamine is the recommended chemical restraint, administered IM at 4 mg/kg (max dose 400 mg).
• Injection sites: mid-shaft anteriolateral aspect of the thigh or lateral deltoid muscle of the shoulder.
• Ketamine can be administered through clothing.

Alternative Chemical Restraint

• If ketamine is not available or the patient becomes agitated as its effects wear off, use lorazepam (Ativan) or midazolam (Versed).
• If vascular access is available:
  • Administer lorazepam 2 mg IV slowly over 1 minute.
  • OR administer midazolam 5 mg IV.
• If vascular access is not available:
  • Administer lorazepam 2 mg IM.
  • OR administer midazolam 10 mg IM/IntraNasal.
• Both medications can be repeated in 3-5 minutes if indicated.

Universal Initial Adult Patient Assessment / Care

• Ensure a maintainable airway.
• Obtain a blood glucose level and treat with dextrose 50% D50W if indicated.
• Monitor cardiac rhythm, ETCO2, and SpO2.
• Provide supplemental O2 if indicated.
• Treat any medical complaint per the appropriate protocol.

Additional Considerations

• If the patient exhibits disrhythmias indicative of metabolic acidosis (e.g., wide QRS and/or loss of P waves), consider administering sodium bicarbonate 1 mEq/kg IV/IO.