Presented by Dr Tony Smith Presentation Synopsis: Agitated delirium, also known as acute severe behavioural disturbance or excited delirium syndrome is not a tightly defined syndrome, but is a well recognised and challenging problem for ambulance, police and emergency department staff.

Severe agitated delirium is a medical emergency and must be treated with a similar level of urgency as status epilepticus. The combination of severe behavioural disturbance, agitation, violence, hyperactivity and physiological excitation/stress may be immediately life threatening for the patient. In addition, the provision of treatment is made more complex because there is often a significant risk of harm to the treating personnel.

Although immediately reversible causes (for example hypoglycaemia) must be excluded, in our experience the majority of cases are secondary to ingestion of recreational drugs and in some patients ruling out a reversible cause requires the administration of sedation before staff can further assess the patient safely. Treating a patient with severe agitated delirium requires a carefully planned approach, usually involving a team of people and often involving both ambulance and police staff. Clear communication, a team leader, good coordination and a backup plan are all important. A combination of both sedation and physical restraint is usually required and a tiered approach to escalation of these in response to the level of the patient’s agitated delirium is recommended.

Bio: Dr Tony Smith is the Medical Director for St John in New Zealand. He is also an Intensive Care Medicine Specialist at Auckland City Hospital.

Tony chairs the working group that develops the Clinical Procedures and Guidelines for the ambulance sector in New Zealand and he oversees all of the clinical aspects of St John activities in New Zealand, noting that the ambulance service is just one aspect of this. He is a member of the New Zealand Resuscitation Council and the Australian and New Zealand Committee on Resuscitation. He has an active involvement in pre-hospital research, with a focus on a collaborative approach to contributing to multi-centre trials. He is a member of the HEMS team in Auckland and has a very active ‘hands on role’ in pre-hospital care.