Excited delirium syndrome is a common yet poorly characterized ED presentation with a wide differential diagnosis. Patients are often identified initially by law enforcement, but attempts to control individuals experiencing ExDS via physical, chemical, or electrical restraints are associated with an exceedingly high rate of morbidity and mortality.

Following transfer to ED stretcher, patient was placed in 4-point soft restraints with a nonrebreather and 100% oxygen with assistance from hospital security; 5 mg/kg ketamine IM was administered, with significant reduction in agitation. The patient was placed on etCO2 and brought to the resuscitation bay for close monitoring. He was found to be tachycardic with a pulse of 150, hypertensive at 150/94, hyperthermic at 39.6° C. End-tidal showed 38mmHg CO2 and 20 respirations/minute. Labs revealed no abnormalities. Cold packs were placed to axilla and groin, and 2 L of cooled lactated ringers was administered IV with improvement in temperature.

Based on the physical exam and history, concern was for excited delirium secondary to an unknown sympathomimetic agent with hallucinogenic qualities, and the patient was admitted to ICU stepdown with supportive care.

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