2014 PSOW Ketamine Update

1. Ketamine for
Prehospital Sedation
in Excited Delirium
Michael D. Curtis, MD, FACEP
Charles E. Cady, MD, FACEP

2. 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

3. 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

4. What is the ideal therapeutic
approach?
 Appropriate supportive therapy
 Fluid resuscitation
 Reversing metabolic acidosis
 Reversing hyperthermia
 Have to control the patient first

5. 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

6. 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

7. 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

8. Post-ketamine Sedation
 Benzodiazepines
 Geodon, Zyprexa
 Haldol, Droperidol

9. 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

10. Adverse reactions
 Hypertension and tachycardia
 Hypotension and bradycardia
 Laryngospasm
 Hypersalivation
 Nausea and vomiting
 Tonic and clonic muscle movements
 Roving eyes or nystagmus

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Wisconsin Ketamine Study
 Exclusion Criteria
 Other uses of Ketamine
 Pain management
 Asthma
 RSI
 Other settings
 Emergency Department
 HEMS
 Critical Care Transport
 ICU
 OR

18. Wisconsin Ketamine Study
 Exclusion Criteria
 Other causes
 Should we exclude head injury cases with
extreme agitation?

19. 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

20. 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

21. 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

22. 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

23. 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

24. Wisconsin Ketamine Study
 What we need from you
 EMS Run Reports (minimum)
 ED Records, Discharge Summaries
(maximum)
 Alternative – Data Collection Form

25. 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?

26. 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

27. Questions