Prehospital use of i.m. ketamine for sedation of violent and agitated patients

Kenneth A Scheppke, Joao Braghiroli, Mostafa Shalaby, Robert Chait, Kenneth A Scheppke, Joao Braghiroli, Mostafa Shalaby, Robert Chait

Abstract

Introduction: Violent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear. The objective is to demonstrate that ketamine, given as a single intramuscular injection for violent and agitated patients, including those with suspected excited delirium syndrome (ExDS), is both safe and effective during the prehospital phase of care, and allows for the rapid sedation and control of this difficult patient population.

Methods: We reviewed paramedic run sheets from five different catchment areas in suburban Florida communities. We identified 52 patients as having been given intramuscular ketamine 4 mg/kg i.m., following a specific protocol devised by the EMS medical director of these jurisdictions, to treat agitated and violent patients, including a subset of which would be expected to suffer from ExDS. Twenty-six of 52 patients were also given parenteral midazolam after medical control was obtained to prevent emergence reactions associated with ketamine.

Results: Review of records demonstrated that almost all patients (50/52) were rapidly sedated and in all but three patients no negative side effects were noted during the prehospital care. All patients were subsequently transported to the hospital before ketamine effects wore off.

Conclusion: Ketamine may be safely and effectively used by trained paramedics following a specific protocol. The drug provides excellent efficacy and few clinically significant side effects in the prehospital phase of care, making it an attractive choice in those situations requiring rapid and safe sedation especially without intravenous access.

Figures

Figure
Figure
Prehospital ketamine protocol flowchart. IM, intramuscular; IV, intravenous; IO, intraosseous infusion; EtCO2, end tidal CO2; BVM, bag-valve-mask; RSI, rapid sequence intubation

References

    1. Vilke GM, DeBard ML, Chan TC, et al. Excited delirium syndrome (ExDS): defining based on a review of the literature. J Emerg Med. 2012;43(5):897–905.

    1. Florida Satutes Chapter 401 and Rule 64-J Florida Administrative Code.

    1. Piyush Patel, Hemal Patel, David Roth. General Anesthetics and Therapeutic Gases. In: Brunto Laurence, Chabner Bruce, Knollman Bjorn., editors. Goodman and Gilman The Pharmacologic Basis of Therapeutics. New York NY: McGraw Hill Companies;
    1. Marzuk PM, Tardiff K, Leon AC, et al. Ambient temperature and mortality from unintentional cocaine overdose. JAMA. 1998;27(22):1795.
    1. Lavoie FW. Consent, involuntary treatment and the use of force in an urban emergency department. Ann Emerg Med. 1992;21:25.
    1. Stratton SJ, Rogers C, Green K. Sudden death in individuals in hobble restraints during paramedic transport. Ann Emerg Med. 1995;259:710–12.
    1. Glatter K, Karch SB. Positional asphyxia: inadequate oxygen or inadequate theory? Forensic Sci Int. 2004;141:201–2.
    1. Pollanen MS, Chiasson DA, Cairns JT. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and the community. CMAJ. 1998;12:1603.
    1. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci. 1985;30:873.
    1. Alshayd H, Showkat A, Wall BM. Lactic acidosis in restrained cocaine intoxicated patient. Tenn Med. 2010;103:37–9.
    1. Ho J, Dawes DM, Moore JC, et al. Effect of position and weight force on inferior vena cava diameter-implications for arrest-related death. Forensic Sci Int. 2011;22:256–9.
    1. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med. 1999;6:239.
    1. Staley J, Basile M, Wetli C, et al. Differential regulation of the dopamine transporter in cocaine overdose deaths. NIDA Res Monogr. 1994;141:32.
    1. Staley JK, Hearn WL, Ruttenber AJ, et al. High affinity cocaine recognition sites on the dopamine transporter are elevated in fatal overdose victims. J Pharm Exp Ther. 1994;271:1678.
    1. Melamed E, Oron Y, Ben-Avraham R, et al. The combative multi-trauma patient: a protocol for pre-hospital management. Eur J Emer Med. 2007;14:265–68.
    1. Svenson JE, Abernathy MK. Ketamine for pre-hospital use: new look at an old drug. Am J Emer Med. 2007;25:977–80.
    1. Green SM, Roback MG, Kennedy RM, et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57:449–61.
    1. Porter K. Ketamine in pre-hospital care. Emerg Med J. 2004;21:351–4.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa