Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Excited Delirium, Sedation, and Comments – Part II

Others responded to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

CombatDoc wrote –

Why are medics so scared of sedation?

This is the main problem.

Ignorance leads to fear.

But this does not lead to Yoda quotes.

We should not be arrogant, assuming that we know everything about the drugs we use. That can be just as dangerous as ignorance, but we need to learn more about the medications we use.

Too many people tell us that sedatives and opioids are dangerous. These are probably the safest drugs we use. They have well known side effects, but the side effects are not remotely as common as the Just say No people would have us believe.

We need to base our treatments on understanding, not fear.

If we understand what we are doing, we will continually reassess our patients, but we should do this with every treatment, not just the treatments portrayed as evil.

My favorite comment in a chart of a patient that I suspect of ED is, “Pt arouses to voice and is resting comfortably on the cot.” That is a properly treated patient.


The purpose of sedation is to sedate.

That is a description of a sedated patient. We are not supposed to be producing awake and alert and cooperative patients. That is asking the impossible.

We are supposed to be sedating the patient to the point of both no longer being a danger to himself and no longer being a danger to others. Awake and alert have nothing to do with that.

I have had very good results with initial doses of 5mg IN or IV of Versed and 10mg IM Versed. I always followed up the IN/IV with an IM dose since studies, cannot find the original one, have shown IM as a better route with less resedation needed.

I would prefer to use IV (IntraVenous) midazolam over IM (IntraMuscular), because it wears off pretty quickly when given IV, especially with the exaggerated metabolism of excited delirium patients. The reality of excited delirium is that an IV is usually not practical, so I have to settle for longer duration and less predictable absorption.

I like the idea of the sedative wearing off quickly, because some patients just need to have their excited delirium interrupted. After a period of sedation, some are able to be reasoned with. Some will ask for more sedation, because they realize they cannot control they way their body is acting. This can be like a panic attack. The patient would like to control it, but does not do well without sedation. It should not be a surprise that benzodiazepines are commonly used for panic attack.

How have your results been with IN (IntraNasal) midazolam for excited delirium?

I know there are risks and apnea is one. Not a fan of doing that on purpose but, we can all handle that.

If a medic cannot handle respiratory depression, or apnea, by BLS (Basic Life Support) methods, should that person be allowed to use any ALS (Advanced Life Support) treatments?

We can’t handle simple cases of respiratory depression, but we should still be allowed to play paramedic?


Absolutely not.

I am seeing more and more of these patients and more and more are ending up chemically paralysed on ventilators until the Spice or Bath Salts are out of their system.

I was wrong about bath salts. I did not think this would become a big deal. Maybe I am just getting old and do not understand how stupid people will be to get a high. Maybe I need to chase some kids off of somebody’s lawn, somewhere. 😳

I guess the doctors just don’t have enough faith in the power of leather restraints./

Maybe someday my medical director will give us Ketamine….

That would be great.

Sedation has so many uses, that we our patients are really missing out on an excellent treatment for a variety of conditions.

Shane, so you have a stance that the hyperthermia, lactic/metabolic acidosis, rhabdo, dehydration, extreme hypertension, etc. that leads to renal failure, MODS, cardiac dysrhythmias, stroke and sudden death is not something that needs to be worried about? Last I checked most of those can kill pretty quickly. All those are a direct result of the patient that is out of control and fighting and struggling. My guess is you have never walked in the house to see every piece of furniture, every appliance, bathroom fixtures, windows, etc. all destroyed by a 150lb guy standing there naked and ready to fight. Not a fun call and a VERY dangerous situation for all involved.

The people who deny excited delirium exists are not the people who work in EMS, emergency medicine, or the police.

The people who deny excited delirium exists are the people who deal with patients who have already been sedated by EMS and the ED (Emergency Department).

If we do not sedate these patients, we may miss the last opportunity to save their lives.

All for a lack of understanding of sedation.



  1. “How have your results been with IN (IntraNasal) midazolam for excited delirium?”

    The term “dropping like a sack of potatoes” is the best description. Almost immediate but, very short lived, 15min max. I do prefer to give it IV for the initial dose. We carry 5mg/ml vials and I give 2.5 per nare and then have time to get the IV and redose with 5mg IM for the 25-30 min ride in to the “big” hospital. Per protocols that leaves me with 10mg left at my disposal. I am waiting for a response back from the Medical Director on repeat doses being Ativan after the IN Midazolam. The only reason I do not prefer Ativan in these patients is the slow peak effect compared to the Versed but, it does seam to last longer once it is given.

    The problem I have right now is that my patients end up RSI’d in the ER about 50% of the time because the sedation wears off and they freak out. Unfortunatly ER staff members are getting injured in that process.

    On a side note it works very well for Narcan and I have had great results and a lower rate of overmedication with the Narcan. Have not had the need to use it for pediactric pain control as of yet but, I’m glad I have the ability to do that without having to have an IV.

  2. Granted, I’m no lawyer, but it seems to me the greatest potential for liability is when the standard of care is NOT met, as opposed to when it is.

    So if you have protocols for chemical restraint (as my region does), to me that would imply greater liability for not restraining a patient in need of it and said patient wreaking mayhem and injuring people.

    But that’s just me applying common sense. So it’s probably wrong.

  3. IMHO, the reason for the fear of sedation among politicians and medical directors is the war stories that circulate that they believe. We’ve all heard of the asshole medic who takes a heroin OD to the hospital and slams 2mg Narcan as he’s walking through the ED doors, right? We’ve also heard similar stories about “knocking out whiny patients to shut them up,” and the politicians and absentee medical directors think that’s how paramedics roll these days. And just like the Narcan stories, there are just enough morons out there who actually have done what the story says that the tales are believable; and as many people have pointed out, EMS finds it easier to limit protocols to the lowest common denominator rather than weed out the idiots.

    As for Ketamine, not a chance in hell given that the Partnership at Drugfree.org has declared that it is a “date rape” drug similar to Rohypnol. The Powers That Be barely trust us with opiates, and they’re going to give access to a “date rape” drug? Not while they’re in charge and can limit patient care based on hysterical claims by non-medical people! 🙁

  4. Excited Delirium is an interesting topic mainly due to the fact that many deny its existence and think its only a cover to protect law enforcement from wrongful death prosecution. While the Emergency Medical community knows better, even our physicians differ on how this should be treated in both the pre-hospital and ER settings.

    The use of Ketamine is controversial. Some physicians think it is crazy to use it in the ED and to consider it pre-hospital is unthinkable.

    As far as I know, my service is the only one in the country to allow administration of Ketamine in the pre-hospital setting without a physician’s order in cases of excited delirium. After the first 21 months of this protocol, here is our history:

    23 cases of pre-hospital Ketamine
    23 cases effectively sedated in the field
    1/23 required BVM enroute
    10/23 intubated in the ED
    15/23 admitted
    If not admitted, the average observation time was 457 minutes
    1 death, not related to Ketamine administration

    BTW, if the patient needs to be controlled prior to the IM administration, we prefer that the police use the Tazer.


  6. I was making a joke. Its hard to tell inflection/emotion on the internet :p