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Clinical Atlas Prestige · Evidence-first

Psych VivasEmergency psychiatry

Psych Vivas · Emergency psychiatry

Acute behavioural disturbance and excited delirium — structured clinical viva

Fellowship viva on ABD-first framing, contested ExDS term, droperidol/ketamine, combination ban, prone restraint, capacity.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar called to ED. A 26-year-old man with possible methamphetamine use is in continuous extreme agitation after a police struggle. Temperature 39 C. Security are holding him prone. Notes say 'excited delirium'. Staff ask for IM olanzapine 10 mg with IM midazolam 5 mg now. Discuss terminology, medical priorities, pharmacology with doses, monitoring, restraint risks, capacity/law, and disposition.

Interpretation

Reveal interpretation

Terminology. Prefer ABD / hyperactive delirium with severe agitation. Reject excited delirium as a standalone diagnosis or sole cause of death (ACMT 2023). Document physiology and restraint facts.[1]

Medical priorities. ABCDE, glucose, SpO2, temperature; cooling; stop prolonged prone restraint; airway-ready team. Treat as medical emergency, not forensic labelling exercise.[4][5]

Reject proposed combination. Never IM olanzapine with parenteral midazolam — respiratory depression risk.[4]

Safer plan. IM droperidol 5–10 mg as common ANZ ED first-line for undifferentiated ABD with monitoring; midazolam 5–10 mg IM alternative; ketamine rescue (~4–5 mg/kg IM) if refractory under governance. Observations every 15 minutes for ≥1 hour including temperature. Endpoint calm and rousable.[2][3][4]

Capacity/law/disposition. Decision-specific capacity; least-restrictive local law without invented sections; medical observation until stable then psychiatric disposition as indicated.[4]

Key points

ABD first

Do not certify or formulate with excited delirium alone.

Name doses

Droperidol 5–10 mg IM; ketamine rescue ~4–5 mg/kg IM under protocol.

Never prone long

Prone restraint cardiac arrest risk; combination ban for IM olanzapine + parenteral BZD.
[1] [2] [4] [5]

References

  1. [1]Stolbach AI, Dargan PI, Greller HA, et al. ACMT Position Statement: End the Use of the Term "Excited Delirium" J Med Toxicol, 2023.PMID 37349654
  2. [2]Isbister GK, Calver LA, Page CB, et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study Ann Emerg Med, 2010.PMID 20868907
  3. [3]Isbister GK, Calver LA, Downes MA, Page CB Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department Ann Emerg Med, 2016.PMID 26899459
  4. [4]Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation J Psychopharmacol, 2018.PMID 29882463
  5. [5]Weedn V, Steinberg A, Speth P Prone restraint cardiac arrest in in-custody and arrest-related deaths J Forensic Sci, 2022.PMID 35869602