Résumé
Les services d’urgences préhospitaliers et hospitaliers sont confrontés de plus en plus fréquemment à des états d’agitation et à des épisodes de violence. Dans certains cas, cet état d’agitation présente un caractère extrême et incoercible, nécessitant une contention physique et chimique, et pouvant parfois conduire au décès du patient. Décrite sous le terme d’excited delirium syndrome (ExDS), cette entité n’est pas universellement reconnue et ne dispose pas à l’heure actuelle de définition standardisée. Bien que décrit au xix e siècle déjà, la fréquence de ce syndrome s’est amplifiée avec l’apparition de la consommation de cocaïne aux États-Unis dans la période 1980–2000. L’intervention policière, généralement nécessaire en phase préhospitalière, ainsi que les décès survenus lors de la maîtrise du patient ont contribué à la médiatisation de ce syndrome. Sa physiopathologie n’est pas connue, mais impliquerait une libération massive de catécholamines endogènes, en particulier dans la période qui suit un stress majeur, un effort physique intense (attitude « combative ») ou une contention physique (restriction ventilatoire), et pourrait alors être responsable d’une défaillance cardiaque aiguë potentiellement mortelle, par dysfonction myocardique ou arythmie. Les rares recommandations de prise en charge préconisent principalement d’identifier rapidement les patients, de les maîtriser au plus vite afin de les médicaliser et de pouvoir les sédater.
Urgence vitale, médiatisée et risquée pour les soignants, cette entité mérite d’être mieux comprise et définie. Nous rapportons le cas d’un patient répondant aux critères d’un ExDS et présentons un aperçu des définitions, traitements et physiopathologies exposés dans la littérature.
Abstract
Prehospital and hospital emergency departments faced more and more frequently states of agitation or violence episodes. In some cases, the agitation presents an extreme and uncontrollable character, requiring a physical and chemical restrain, which sometimes can lead to the death of the patient. Referred to Excited Delirium Syndrome (ExDS), this entity is not universally recognised and has at the present time no standardised definition. Although already described in the nineteenth century, the frequency of this syndrome has increased with the appearance of cocaine consumption in the United States during the 1980–2000 period. Police interventions, usually mandatory in the prehospital stage, along with the deaths occurred during the restrain of the patient, contributed to the mediatisation of this syndrome. Its physiopathology is unknown, but it could involve a massive liberation of endogenous catecholamines, particulary during the period following a major stress, an intense physical effort (combative behaviour) and a physical contention (with ventilatory restriction), and could then be responsible of an acute and potentially fatal heart failure, due to myocardial dysfunction or arrhythmia. The recommendations concerning care of these patients principally recommend a rapid identification of this condition and to control the patients as soon as possible, in order to medicalize and sedate them.
This life-threatening emergency, at high risk for the caregivers, is worth being better understood and defined. We report a case of a patient matching the criteria of an ExDS and presenting an insight on the definitions, treatments and pathophysiology issued from the literature.
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Gonin, P., Yersin, B. & Carron, P.N. Agitation extrême: concept d’excited delirium . Ann. Fr. Med. Urgence 4, 33–38 (2014). https://doi.org/10.1007/s13341-013-0376-4
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DOI: https://doi.org/10.1007/s13341-013-0376-4