Severe forms of sepsis are major contributors to morbidity and mortality worldwide, with mortality rates as high as 25%-60%. 1 Sepsis with hypotension and septic shock, which we define as sepsis with a systolic blood pressure ≤ 90 mm Hg that is refractory to an initial fluid bolus, 2 are important subsets of sepsis and are medical emergencies for which timeliness of care is crucial. The literature demonstrates that early administration of antibiotics provides a significant mortality benefit in both conditions. 1 Emergency medical services (EMS) personnel treat the majority of sepsis with hypotension and septic shock cases. 2 Consequently, oversight entities, including the Centers for Medicare & Medicaid Services, are recognizing that EMS providers are an important link in ensuring timely care for patients with sepsis. 3 A natural extension of current initiatives to reduce time to antibiotic administration in patients who exhibit sepsis with hypotension or septic shock is to consider implementing prehospital administration of antibiotics.Research regarding the feasibility of this practice and its effectiveness has primarily been performed in Europe. [4][5][6] Few American systems have begun examining similar prehospital antibiotic administration protocols. 7,8 These early studies have demonstrated evidence of improved patient outcomes including shorter intensive care unit (ICU) lengths of stay. 7,8 The primary aim of our investigation was to describe the safety and feasibility of a protocol for prehospital recognition of sepsis with hypotension and septic shock, drawing of blood cultures, and administration of intravenous (IV) antibiotics in an urban EMS service, thereby adding to the limited U.S. literature available on this subject and supporting the development of a large-scale randomized control trial (RCT). Primary feasibility measures included the frequency of allergic reactions, culture contamination, and paramedic adherence to the protocol in the prehospital environment. Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) were used to report the findings of this preliminary result. 9This pilot study was conducted at a large urban academic medical center under a state-granted special project waiver for the protocol implementation. This two-armed project consisted of a retrospective chart review for the historical cohort and a prospective observational study for the interventional arm.

Background: Agitated behaviors are frequently encountered in the prehospital setting and require emergent treatment to prevent harm to patients and prehospital personnel. Chemical sedation with ketamine works faster than traditional pharmacologic agents, though it has a higher incidence of adverse events, including intubation. Outcomes following varying initial doses of prehospital intramuscular (IM) ketamine use have been incompletely described. Objective: To determine whether using a lower dose IM ketamine protocol for agitation is associated with more favorable outcomes. Methods: This study was a pre-/post-intervention retrospective chart review of prehospital care reports (PCRs). Adult patients who received chemical sedation in the form of IM ketamine for agitated behaviors were included. Patients were divided into two cohorts based on the standard IM ketamine dose of 4mg/kg and the lower IM dose of 3mg/kg with the option for an additional 1mg/kg if required. Primary outcomes included intubation and hospital admission. Secondary outcomes included emergency department (ED) length of stay, additional chemical or physical restraints, assaults on prehospital or ED employees, and documented adverse events. Results: The standard dose cohort consisted of 211 patients. The lower dose cohort consisted of 81 patients, 17 of whom received supplemental ketamine administration. Demographics did not significantly differ between the cohorts (mean age 35.14 versus 35.65 years; P = .484; and 67.8% versus 65.4% male; P = .89). Lower dose subjects were administered a lower ketamine dose (mean 3.24mg/kg) compared to the standard dose cohort (mean 3.51mg/kg). There was no statistically significant difference between the cohorts in intubation rate (14.2% versus 18.5%; P = .455), ED length of stay (14.31 versus 14.88 hours; P = .118), need for additional restraint and sedation (P = .787), or admission rate (26.1% versus 25.9%; P = .677). In the lower dose cohort, 41.2% (7/17) of patients who received supplemental ketamine doses were intubated, a higher rate than the patients in this cohort who did not receive supplemental ketamine (8/64, 12.5%; P <.01). Conclusion: Access to effective, fast-acting chemical sedation is paramount for prehospital providers. No significant outcomes differences existed when a lower dose IM ketamine protocol was implemented for prehospital chemical sedation. Patients who received a second dose of ketamine had a significant increase in intubation rate. A lower dose protocol may be considered for an agitation protocol to limit the amount of medication administered to a population of high-risk patients.