Ketamine for Excited DeliriumRFFE ALS Waiver Training

Exicted Delirium

No universally recognized definition

“a syndrome of uncertain etiology characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction”

“characteristic symptoms of bizarre and aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength, and hyperthermia.”

typically present with any combination of agitation, heightened pain tolerance, tachypnea, and diaphoresis; these patients have a propensity to develop severe acidemia with progression to sudden cardiac arrest.

Excited Delirium

Common yet poorly characterized ED presentation with a wide differential diagnosis.

Catecholaminergic excess involving:1 - endogenous stress‐related catecholamines2 - exogenous catecholaminergic drugs3 - overstimulation of dopamine and NMDA glutamate receptors in the

setting of psychiatric or organic medical illness.

Causes can be grouped broadly into metabolic/endocrine, neurologic, infectious, toxicologic, and psychiatric etiologies

Excited Delirium

Reported for over 100 years

Rising incidence in the 1980s linked to increased use of cocaine,amphetamines, and phencyclidine.

Recently, synthetic cathinones and cannabinoids have been implicated.

Colorado Revised Statutes

Title 26 - Human Services CodeArticle 20 - Protection of Persons From Restraint

CO Restraint Act 26-20-102Definitions

"Chemical restraint" means giving an individual medication involuntarily for the purpose of restraining that individual; except that "chemical restraint" does not include the involuntary administration of medication pursuant to section 27-10-111 (4.5), C.R.S., or administration of medication for voluntary or life-saving medical procedures.

"Emergency" means a serious, probable, imminent threat of bodily harm to self or others where there is the present ability to effect such bodily harm.

Physical restraint" means the use of bodily, physical force to involuntarily limit an individual's freedom of movement; except that "physical restraint" does not include b) The use of protective devices or adaptive devices for providing physical support, prevention of injury, or voluntary or life-saving medical procedures;(c) The holding of an individual for less than five minutes by a staff person for protection of the individual or other persons;

CO Restraint Act 26-20-103Basis for Use of Restraint

(6) The provisions of this article do not apply to any agency engaged in transporting an individual from one facility or location to another facility or location when it is within the scope of that agency's powers and authority to effect such transportation.

In cases of emergency, as defined in section 26-20-102 (3); and(b) (I) After the failure of less restrictive alternatives; or(II) After a determination that such alternatives would be inappropriate or ineffective under the circumstances.

• Only for the purpose of preventing the continuation or renewal of an emergency• Only for the period of time necessary to accomplish its purpose• In the case of physical restraint, only if no more force than is necessary to limit the

individual's freedom of movement is used.

CO Restraint Act 26-20-104Duties Relating to Use of Restraint

• Monitor position to not result in circulatory or respiratory compromise every 15 min

• A chemical restraint is the least restrictive, most appropriate alternative available.

Excited Delirium vs Severe Agitation?

Defined as a score of +4 on the Altered Mental Status Scale (AMSS)

-4 (unresponsive) to +4 (most agitated).

RFFE Protocols

PrecautionsHypertensivePre-existing tachyarrythmia

Dose5mg/kg IM

RequirementsPrepare to for RSI/Intubation

Adverse EventsHypersalivation(18%) - AtropineVomiting(6%) - OndansetronRespiratory Depression(15 to 35%) – Support/IntubateEmergence (4%) - Diazepam

Ketamine Pharmacology5mg/kg

Commercially available in 1970

Derived from PCP

Dissociative Anesthetic (catatonia, catalepsy, amnesia)

Analgesic (on-par with opioids)

Anti-inflammatory (by suppression of pro-inflammatory cytokines)

Anti-depressant

Onset of Action 3 to 5 minutes (up to 12 minutes faster than haloperidol)

Duration of Action 12 to 30 minutes

State Waiver Justification

Ketamine has a rapid onset of effectiveness in Excited Delirium that enhances the safety of our patients and crews. The onset of action for IM Ketamine approaches 3 minutes which is up to 12 minutes faster than haloperidol. The literature supports that Ketamine is safe to use at doses matching RFFRA’s protocol of 5mg/kg. The predominant adverse effects are hypersalivation, vomiting and emergence reaction. There is also a growing trend of evidence to suggest a higher incidence of intubation as compared to haloperidol; though most intubations occurred after arriving at the emergency department. It is RFFRA’s stance that the rapid onset of action of Ketamine for a patient with Excited Delirium, who may cause harm to self or others, significantly outweighs the incidence of adverse events that are readily managed and clearly within the scope of care of the paramedics caring for the patient.