Ketamine for Prehospital Sedation in Excited Delirium

Michael D. Curtis, MD, FACEP

Charles E. Cady, MD, FACEP

Introduction

Acute delirium with violent agitation may lead to sudden unexpected cardiac arrest in previously healthy persons

Struggling during arrest procedures and continued struggle after physical restraints have been applied appear to be major risk factors

What is the ideal therapeutic approach? Remains to be determined Rapid effective tranquilization

IM or IN administration Little or no adverse cardiovascular and

respiratory side effects Facilitates rapidly instituting resuscitative

measures

What is the ideal therapeutic approach? Appropriate supportive therapy

Fluid resuscitation Reversing metabolic acidosis Reversing hyperthermia

Have to control the patient first

Indications

To control agitated and combative behavior Law Enforcement

When the subject is resisting forcefully or continuing to struggle against restraints

EMS When the patient poses a significant threat of

harm to self or others, including the EMS crew

Prehospital Goals of Therapy

Quickly and effectively gain subject/patient compliance with a single dose

Prevent violent struggle with police and ongoing struggle against restraints

Gain IV access for fluid and medication administration

Initiate supportive therapies Transport to the emergency department for

definitive evaluation and management

Dosages

Ketamine 5 mg/kg IM Repeat Dosages

Requires an order from medical control 1 – 2 mg/kg IM 1 mg/kg IV slowly over 60 seconds

Dilute the desired dose of the 100mg/ml formulation with an equal volume of NS or D5W

Incompatible with diazepam in the same syringe

Post-ketamine Sedation

Benzodiazepines Geodon, Zyprexa Haldol, Droperidol

Patient Monitoring and Support

Prevent vomiting with aspiration Mild tachycardia and hypertension are

expected Hypotension and bradycardia occasionally

occur Transient respiratory depression occasionally

occurs Laryngospasm may produce mild stridor

Adverse reactions

Hypertension and tachycardia Hypotension and bradycardia Laryngospasm Hypersalivation Nausea and vomiting Tonic and clonic muscle movements Roving eyes or nystagmus

Psychological Adverse Reactions

Occur in about 12% of patients Ages 15 – 45 Short lived (hours) Preventable with administration of

benzodiazepines Visual Hallucinations Nightmares Emergence Delirium Sensation of detachment from the body

Wisconsin Ketamine Study

Portage County Beloit Eau Claire Lake Country Baraboo Madison Oshkosh Fond du Lac Brown County

Gundersen Tri-State Antigo Wausau Baldwin West Bend De Pere SAFER

Wisconsin Ketamine Study

Froedtert & Medical College of Wisconsin IRB (Institutional Review Board) Approval Any cases prior to September 13, 2013

Extension to 9-30-2014 request pending Principal investigators:

Charles E. Cady, MD – Froedtert-MCW Michael D. Curtis, MD – Ministry Health Care

Wisconsin Ketamine Study

Waivers Informed Consent Waiver

We do not need to obtain informed consent from the participants to enroll them in the study

HIPAA Waiver EMS run reports and related documents can be

shared with the principal investigators

Wisconsin Ketamine Study

Inclusion Criteria Cases in Wisconsin EMS systems Ketamine used to control agitated, combative

or violent behavior In custody of law enforcement Significant threat to self or others, including

emergency responders Adult and pediatric cases Any gender Any race

Wisconsin Ketamine Study

Inclusion Criteria Causes:

Stimulant and other drug abuse Psychiatric disease

New onset Recrudescent disease Psychiatric drug “withdrawal” syndromes

Alcohol intoxication Developmental and cognitive disorders Agitated Dementia

Wisconsin Ketamine Study

Exclusion Criteria Other uses of Ketamine

Pain management Asthma RSI

Other settings Emergency Department HEMS Critical Care Transport ICU OR

Wisconsin Ketamine Study

Exclusion Criteria Other causes

Should we exclude head injury cases with extreme agitation?

Wisconsin Ketamine Study

Procedure All documents should be in pdf format Include:

At a minimum: EMS run reports and any supporting documents

Would be nice: Corresponding ED records At the maximum: Hospital discharge summary

Please keep them grouped together by case

Wisconsin Ketamine Study

Procedure (Cont’d) Let me know via email when you are ready to

send them I will send you a secure email using Data

Motion Attach the records to that email and return

them You may have to do each case separately or

send small groups of cases

Wisconsin Ketamine Study

Procedure (Cont’d) Do not redact any information, like patient

identifiers I will store them all in a password protected file

and password protect the documents I will extract all study data to data forms and

also store them securely I will manage a spreadsheet with all the data

and store it securely I will not print paper copies of any protected

information

Wisconsin Ketamine Study

If I have questions I may contact you I may discuss the cases with Dr. Cady

I will not divulge any protected information to any other persons, except in aggregate form

I will not review these cases for quality of care purposes or provide feedback

Wisconsin Ketamine Study

What we need from you Review our IRB Application and Approval

Decide if you will participate Primary contact, email and phone Protocols, Policies, Procedures Population you serve Geographic area of service coverage

Wisconsin Ketamine Study

What we need from you EMS Run Reports (minimum) ED Records, Discharge Summaries

(maximum) Alternative – Data Collection Form

Wisconsin Ketamine Study

State EMS Office Can you give us a list of services approved to

use Ketamine? Can you help us to distribute notice of the

study to all services in Wisconsin?

Wisconsin Ketamine Study

Our contact information Michael D. Curtis, MD Michael.Curtis@ministryhealth.org 715-498-2240

Charles E. Cady, MD cecady@mcw.edu 262-501-4880

Questions