Acute behavioural disturbance and contested excited delirium (MEQ)

(i) Terminology and documentation. Prefer acute behavioural disturbance (ABD) / severe behavioural disturbance or hyperactive delirium with severe agitation. Excited delirium is not a DSM-5-TR or ICD-11 diagnosis; ACMT 2023 and critical reviews advise against using it as a diagnosis or sole cause of death. Document observed facts: continuous extreme agitation, hyperthermia, tachycardias, prolonged struggle, prone restraint, possible stimulant use. Avoid racialised or thought-terminating labels that skip investigation of restraint contribution and medical drivers.[1][2][6]

(ii) Immediate medical priorities. This is a medical resuscitation: ABCDE already partly captured; continue airway readiness, oxygen as needed, continuous observation. Stop prolonged prone hold as soon as control allows; reassess ventilation; prefer recovery-safe positioning. Active cooling for temperature 39.4 C. Large-bore IV access when safe; prepare for rhabdomyolysis and acidosis. Team roles; one lead communicator if any de-escalation window appears. Endpoint later is calm and rousable, not unconscious.[5][6]

(iii) Safer sedation pathway. Do not combine IM olanzapine with parenteral midazolam. In ANZ ED undifferentiated severe ABD, a common evidence-supported first-line is IM droperidol 5–10 mg with monitoring; IM midazolam 5–10 mg is an alternative with higher airway vigilance. If refractory and airway-skilled staff present, ketamine rescue under local protocol (commonly around 4–5 mg/kg IM). Post-dose: continuous observation; RR, SpO2, BP, HR, consciousness, temperature every 15 minutes for at least 1 hour. Never leave unmonitored.[3][4][5]

(iv) Investigations and differential. Immediate: serial vitals, glucose (done), ECG when practicable, CK, U&E, FBC, VBG/ABG if severe exertion/collapse risk. Do not delay sedation for urine drug screen. Differential: stimulant toxicity, primary psychosis/mania, delirium (sepsis, trauma, encephalitis), withdrawal, serotonin toxicity/NMS, head injury, hypoglycaemia/hypoxia already partly addressed. Targeted further tests for red flags.[5]

(v) Capacity, law, disposition. Capacity is decision-specific; extreme ABD with hyperthermia and continuous thrashing likely impairs capacity for remaining and treatment — document explicitly when feasible. Use emergency treatment principles and local Mental Health Act for ongoing psychiatric care without inventing section numbers; least-restrictive options when safer. Disposition: medical observation/ICU if deep sedation, ongoing hyperthermia, rhabdomyolysis, or airway need; psychiatric admission once medical risk controlled. Immediate discharge is inappropriate.[5]