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Excited Delirium

ExDS is characterized by extreme agitation and aggression in a patient with altered mental status.


  • Recognize excited delirium syndrome (ExDS);
  • Describe the pathophysiology of ExDS;
  • Know potential causes of ExDS;
  • Describe the treatment of ExDS.


1. Vilke GM, DeBard ML, Chan TC, et al. Excited Delirium Syndrome (ExDS): defining based on a review of the literature. J Emerg Med, 2012 Nov; 43(5): 897-905.

2. Lipsedge M. Excited delirium: A psychiatric review. Med Sci Law, 2016; 56(2): 121-7.

3. ACEP Excited Delirium Task Force. White Paper Report on Excited Delirium Syndrome,

4. National Highway Traffic Safety Administration. National Emergency Medical Services Education Standards,

5. Jouvenal J. 'Excited delirium' cited in dozens of deaths in police custody. Is it real or a cover for brutality? Washington Post, 2015 May 6;

6. Benzer TI, Nejad SH, Flood JG. Case records of the Massachusetts General Hospital. Case 40-2013. A 36-year-old man with agitation and paranoia. N Engl J Med, 2013 Dec 26; 369(26): 2,536-45.

7. Kesha K, Boggs CL, Ripple MG, et al. Methylenedioxypyrovalerone ("bath salts"), related death: case report and review of the literature. J Forensic Sci, 2013 Nov; 58(6): 1,654-9.

8. Ruttenber AJ, Lawler-Heavner J, Yin M, et al. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J Forensic Sci, 1997 Jan; 42(1): 25-31.

9. Schiavone SNeri MMhillaj E, et al. The role of the NADPH oxidase derived brain oxidative stress in the cocaine-related death associated with excited delirium: A literature review. Toxicol Lett, 2016 Sep 6; 258: 29-35.

10. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med, 1999 Mar; 6(3): 239-43.

11. Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome. Am J Forensic Med Pathol, 1999 Jun; 20(2): 120-7.

12. Takeuchi A, Ahem TL, Henderson SO. Excited Delirium. West J Emerg Med, 2011 Feb; 12(1): 77-83.

13. Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and positional asphyxia. Ann Emerg Med, 1997 Nov; 30(5): 578-86.

14. Bozeman WP, Ali K, Winslow JE. Long QT syndrome unmasked in an adult subject presenting with excited delirium. J Emerg Med, 2013 Feb; 44(2): e207-10.

15. Roach B, Echols K, Burnett A. Excited Delirium and the Dual Response: Preventing In-Custody Deaths. FBI,

16. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med, 2012 Feb; 13(1): 17-25.

17. Hayes BD. Ketamine for Excited Delirium Syndrome. Academic Life in Emergency Medicine,

18. Scheppke KA, Braghiroli J, Shalaby M, Chait R. Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients. West J Emerg Med, 2014 Nov; 15(7): 736-41.

19. Burnett AM, Peterson BK, Stellpflug SJ, et al. The association between ketamine given for prehospital chemical restraint with intubation and hospital admission. Am J Emerg Med, 2015 Jan; 33(1): 76-9.

20. Bellolio MF, Gilani WI, Barrionuevo P, et al. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med, 2016 Feb; 23(2): 119-34.

21. Lulla A, Singh M. The Art of the ED Takedown. emDocs,

22. Vilke GM, Bozeman WP, Dawes DM, Demers G, Wilson MP. Excited delirium syndrome (ExDS): treatment options and considerations. J Forensic Leg Med, 2012 Apr; 19(3): 117-21.

23. Miami-Dade Fire Rescue. Medical Operations Manual,

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