Step 1 · Recognize
- Severe agitation + violence + superhuman strength + insensitivity to pain
- Hyperthermia (often > 40°C), diaphoresis, tachycardia, tachypnea, mydriasis
- Often stimulant intoxication (cocaine, methamphetamine, PCP, synthetic cathinones)
- HIGH risk of sudden cardiac arrest after restraint — never prone-restrain
Step 2 · Rapid sedation (first dose now)
- Ketamine 4–5 mg/kg IM (or 1–2 mg/kg IV) — onset 2–5 min IM · prep airway
- Alt: Midazolam 5–10 mg IM/IV q5–10 min if ketamine unavailable
- Alt: Droperidol 5–10 mg IM/IV · Olanzapine 10 mg IM (avoid with benzo + EtOH)
- Avoid haloperidol monotherapy — slower onset, QT risk in already-hot patient
- Release physical restraints as soon as chemically sedated
Step 3 · Cool aggressively (target core < 38.5°C)
- Strip clothing · ice packs to neck / axilla / groin · cooling blanket
- Cold NS bolus 30 mL/kg · evaporative cooling (mist + fan)
- Continuous rectal/esophageal/bladder temp probe
- Stop active cooling at 38.5°C to avoid overshoot
Step 4 · Resuscitate, work-up, monitor
- Continuous cardiac + SpO₂ + temp + capnography · airway adjuncts ready
- POC glucose, lactate, K, Ca, CK, troponin, VBG, UDS, ECG, β-hCG
- Aggressive IVF for rhabdo (UOP > 1–2 mL/kg/hr)
- Hyper-K: CaGluc 1 g IV + Insulin 10 U + D50 25 g + Albuterol 10 mg neb
- Acidosis pH < 7.2 → NaHCO₃ 1–2 mEq/kg IV
- Treat arrhythmia per ACLS · avoid epinephrine in cocaine arrest if alternative
Step 5 · Disposition
- ICU admission for IV sedation, cooling, rhabdo monitoring
- Intubate if obtunded after sedation, refractory hyperthermia, or rising lactate
- Psychiatry/SUD consult once medically stable + sober