The agitated stimulant patient — escalation viva

This is excited delirium — agitation with hyperthermia, autonomic storm, pain indifference and continuous struggle — a time-critical medical emergency, not a containment problem. The combination of methamphetamine use, hyperthermia (39.6), tachycardia (152), hypertension, tachypnoea, diaphoresis and rigidity in a patient held prone by four officers for 12 minutes is the exact pattern the forensic literature on restraint-associated sudden death describes, and the patient is at imminent risk of positional asphyxia, hyperkalaemic arrhythmia, rhabdomyolysis, cardiovascular collapse and death.^[1]

The immediate priority is to release prone restraint and reposition supine or lateral, while a sufficient clinical team (not police alone) takes over.^[1] Airway, breathing, circulation are assessed in parallel. The bedside glucose is done (normal, excluding hypoglycaemia).^[4] A resuscitation team is summoned. High-flow oxygen is applied. Intravenous access is secured as soon as the patient is chemically controlled.

Chemical control is the priority because physical containment is the mechanism of death.^[1] First-line is a high-dose benzodiazepine plus droperidol intramuscularly — lorazepam 1 to 2 mg IM or midazolam 5 to 10 mg IM, with droperidol 5 to 10 mg IM. The Cole 2026 trial confirms droperidol as effective first-line for methamphetamine-associated agitation.^[2] For refractory agitation, ketamine 4 mg per kg IM for dissociative control is used in the specialist or pre-hospital setting, with full airway equipment immediately available, recognising the risks of hypersalivation, emergence and laryngospasm. Active cooling is begun immediately: remove clothing, evaporative cooling with tepid water and fans, ice packs to the groins, axillae and neck; consider cold intravenous fluids. Hyperkalaemia and acidosis are anticipated and treated: a venous gas is drawn, and hyperkalaemia is treated with intravenous calcium chloride or gluconate, insulin with dextrose, and salbutamol; acidosis is corrected with ventilation and, where appropriate, sodium bicarbonate. Rhabdomyolysis is anticipated: intravenous fluid loading to maintain a urine output of 1 to 2 mL per kg per hour, and a creatine kinase level is sent.^[1]

The complications to anticipate are torsades de pointes from droperidol-related QT prolongation (pre-sedation and post-sedation ECG, electrolyte correction), aspiration in the over-sedated patient (lateral positioning, airway adjunct), acute kidney injury from rhabdomyolysis (fluid, monitoring), disseminated intravascular coagulation, hepatic dysfunction, and sudden death — the catastrophic outcome that chemical control, cooling and electrolyte correction are designed to prevent. Intubation and mechanical ventilation with lung-protective settings is the escalation for the patient who cannot be controlled medically, who has a rising lactate or worsening acidosis, or whose airway cannot be safeguarded.^[1]