Ketamine is being used with increasing frequency in the prehospital setting for sedation of the agitated patient. Ketamine received some bad press in the summer of 2018 which resulted in putting the prehospital study of the use of ketamine in agitated patients on hold in Minneanapolis, MN. With increased use, we wanted to provide a succint review of ketamine and its use specifically for sedation. This is different than using ketamine for analgesia, which we will discuss in an upcoming episode.
Ketamine Fast Facts:
- Developed as an anesthetic
- Dissociative agent
- Both amnestic and analgesic properties
- Administer IM, IV, IO, IN
- Dose: 1-2 mg/kg IV/IO; 4-5 mg/kg IM/IN
- Onset: 2 min IV/IO; 5-10 min IM/IN
- Emergence reaction
- Intubation (rare)
- Hypoxia (rare)
Take Home Message:
Ketamine is a reasonable choice for gaining control of the severely agitated patient, preventing injury to the patient, rhabdomyolysis and provider injury by accomplishing a reasonable level of sedation with infrequent side effects. The varying rate of intubation calls for additional study to tease out the factors leading to the higher rate of intubation seen in a couple of the studies.
Burnett AM, Salzman JG, Griffith KR, Kroeger B, Frascone RJ. The emergency department experience with prehospital ketamine: a case series of 13 patients. Prehospital Emergency Care 2012;16(4):553-559.
Cole JB, Klein LR, Nystrom PC, Moore JC, Driver BE, Fryza BJ, Harrington J, Ho JD. A prospective study of ketamine as primary therapy for prehospital profound agitation. American Journal of Emergency Medicine 2018;36(5):789-796
Cole JB, Moore JC, Nystrom PC, Orozco BS, Stellpflug SJ, Kornas RL, Fryza BJ, Steinberg LW, O’Brien-Lambert A, Bache-Wiig P, Engebretsen KM, Ho JD. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clinical Toxicology 2016;54(7):556-562.
Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP. Ketamine use for acute agitation in the emergency department. The Journal of Emergency Medicine 2015;48(6):712-719.
Keseg D, Cortez E, Rund D, Caterino J. The use of prehospital ketamine for control of agitation in a metropolitan firefighter-based EMS system. Prehospital Emegency Care 2015;19(1):110-115.
Mion G, Villevieille T. Ketamine pharmacology: an update (pharmacodynamics and molecular aspects, recent findings). CNS Neuroscience & Therapeutics 2013;19(6):370-380.
Olives TD, Nystrom PC, Cole JB, Dodd KW, Ho JD. Intubation of profoundly agitated patients treated with prehospital ketamine. Prehospital and Disaster Medicine 2016;31(6):593-602.
Riddell J, Tran A, Bengiamin R, Hendey G, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. American Journal of Emergency Medicine 2017;35(7):1000-1004.
Scheppke KA, Braghiroli J, Shalaby M, Chait R. Prehospital use of IM ketamine for sedation of violent and agitated patients. Western Journal of Emergency Medicine 2014;15(7):736-741.