Who is at Greatest Risk?

How do we identify those patients presenting with ABD who are at greatest risk of significant morbidity or mortality?

A ‘Best BET’ from 2013 highlights that early recognition of ABD is key, as often there is no warning that sudden cardiovascular collapse is to occur.⁵ ‘Laboured respiratory efforts’ have been noted prior to death and reinforce the need for prompt airway and haemodynamic control. Other aspects highlighted were that patients may be better controlled chemically than by physical restraint, and those with hyperthermia and acidosis should be aggressively managed to reduce agitation and restore normal physiological parameters.

The American College of Emergency Physicians (ACEP) Excited Delirium Task Force report published in 2009 describes the following observed clinical features in patients with ABD that have died³:

• Male subjects, average age 36
• Destructive or bizarre behaviour generating calls to police
• Suspected or known psycho-stimulant drug or alcohol intoxication
• Suspected or known psychiatric illness
• Nudity or inappropriate clothing for the environment
• Failure to recognise or respond to police presence at the scene (reflecting delirium)
• Erratic or violent behaviour
• Unusual physical strength and stamina
• Ongoing struggle despite futility
• Cardiopulmonary collapse immediately following a struggle or very shortly after quiescence
• Inability to be resuscitated at the scene, and
• Inability for a pathologist to determine a specific organic cause of death
• Attraction to glass or reflective surfaces (less frequent than all others as found in a Canadian study)