Midazolam vs Ketamine for Hyperactive delerium

So let's talk about combative patients. I feel like there's a bit of a knowledge/training gap in the implementation of the ketamine component of sedation. I get why we're administering a whack of dissociative to a highly violent and agitated pt - it's effective, and rapidly eliminates the immediate physical risk to pt and crew. But when we look at hyperactive delerium, and realize that the proximal cause in many (most?) cases is the use of stimulants/sympathomimetics, I wonder why our proscribed front-line med is one that has a not-insignificant risk of potentiating these effects. Would our benzo, midazolam, not be more appropriate in this situation particularly if the cause is rooted in stimulant use? Sure, we should be trying to establish a hx, but how exhaustive can one be when faced with an immediate threat? I just worry that we might be putting our pts at risk by effectively not addressing the underlying cause. Tldr; wouldn't Midaz be better for hyperactive delerium?

Midazolam and Ketamine are both very effective sedatives. The important piece to remember about hyperactive delirium (AKA excited delerium) is that it is a life-threatening condition that requires timely intervention. In the setting of hyperactive delirium, the patient is hyperthermic and acidotic and at high risk of sudden cardiac arrest. With that in mind, we want to use Ketamine as the sedative of choice because of the following; its fast onset of action, it protects airway reflexes, and it does not cause any cardiac instability/irritation. When on the fence, you can also consider how volatile and combative the patient is- If you feel that you or your partner are in imminent danger or the patient is an imminent risk to others, Ketamine is probably the better choice.

Midazolam is a great drug to use when dealing with a combative patient that isn't in that life-threatening excited delirium state.

Please Note: Excited delirium is a term that has fallen out of favour because it has racial undertones and is frequently attributed to people of colour being dissociated because of their aggression rather than a true objective violence or danger. The nomenclature is moving towards the term hyperactive delirium as used in original question.

There are some references that we have attached below.