A prospective study of ketamine versus haloperidol for severe prehospital agitation

Cole, Jon B.; Moore, Johanna C.; Nystrom, Paul C.; Orozco, Benjamin S.; Stellpflug, Samuel J.; Kornas, Rebecca L.; Fryza, Brandon J.; Steinberg, Lila W.; O’Brien-Lambert, Alex; Bache-Wiig, Peter; Engebretsen, Kristin M.; Ho, Jeffrey D.

doi:10.1080/15563650.2016.1177652

Cited by 105 publications

(80 citation statements)

References 31 publications

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“…Moreover, in a study of a Danish population of over 2 million, Laursen et al reported that the chance of a bipolar woman being admitted with the diagnosis of schizoaffective disorder was 103 times higher than the general population of the same age [8]. Due to the unfavorable side effect profile of ketamine and safety and efficacy of antipsychotics, ketamine is used less often but successfully in the emergency setting for agitation [13][14][15]. The patient, who carried a diagnosis of schizoaffective disorder, in this report, was given 300 mg of intramuscular ketamine for combative behavior.…”

Section: Discussionmentioning

confidence: 99%

Ketamine Role in Schizoaffective Disorder Depressive Type

Aziz¹,

Babb²,

Brown³

et al. 2017

J Addict Res Ther

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Ketamine use for patients with severe treatment-resistant depression continues to be an area of interest due to the relatively limited number of treatment options for those patients. Although its use as a treatment option for patients with schizophrenia and schizoaffective disorder may seem counterintuitive, in this case report, we explore the efficacy of ketamine for depressive episodes in schizoaffective disorder. This patient who carried a diagnosis of schizoaffective disorder was given 300 mg of intramuscular ketamine for agitation. However, over the course of four days of inpatient stay, her depression drastically improved. She met criteria for remission with the Hamilton Rating Scale for Depression (HAM-D) score of 4, down from an initial score of 21. We advocate for a better understanding of the pros and cons of using ketamine for depression in schizoaffective disorders considering the controversy over the diagnosis of schizoaffective disorder, especially in African American population. At the urging of reducing the risk of suicide among this group and improving their quality of life as well as reducing financial burden by shortening total duration of hospitalization, it may be worthwhile to explore the feasibility of ketamine as a treatment option for severe depression in these patients, possibly as a last resort.

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Section: Discussionmentioning

confidence: 99%

Ketamine Role in Schizoaffective Disorder Depressive Type

Aziz¹,

Babb²,

Brown³

et al. 2017

J Addict Res Ther

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show abstract

“…Two studies evaluated IM ketamine in comparison with IM haloperidol. A 12‐month study compared IM ketamine dosed at 5 mg/kg (64 patients [44%]) with IM haloperidol dosed at 10 mg (82 patients [56%]) in the prehospital setting for undifferentiated agitation to determine which agent was superior for sedation . More than half of the patients in both groups had a history of mental illness, and more than 25% in both groups had a history of mental illness in combination with substance use.…”

Section: Literature Reviewmentioning

confidence: 99%

“…Emergency medical service responders have extensive experience with IM midazolam because it is the preferred IM agent in the management of status epilepticus and has a rapid onset of action and short duration of action when compared with other benzodiazepines . Although some studies utilized midazolam as adjunct sedation, there is potential concern that such a practice may compound the risk of respiratory compromise . Protocols for ketamine use in the prehospital setting should also include atropine or glycopyrrolate for management of hypersalivation .…”

Section: Practical Applicationsmentioning

confidence: 99%

“…Agitation is a symptom of many medical and psychiatric disorders that can manifest along a spectrum of severity; therefore, not all presentations of agitation require emergency interventions. Currently, a uniform definition of agitation as a disease state is lacking due to the variety of terminologies used; however, validated scales such as the altered mental status scale (AMSS) aid in defining the severity of agitation . The current literature discusses “agitation” as well as “excited delirium,” a subtype of agitation that includes mental status changes in combination with psychomotor agitation, metabolic derangements, and hyperthermia, potentially leading to death .…”

mentioning

confidence: 99%

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Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting

2017

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Traditional first-line therapy in the prehospital setting for the acutely agitated patient includes an antipsychotic in combination with a benzodiazepine. Recently, interest has grown regarding the use of ketamine in the prehospital setting as an attempt to overcome the limitations of the traditional medications and provide a more safe and effective therapy. This review provides an overview of the pharmacology of ketamine, evaluates the literature regarding ketamine use for prehospital agitation, and proposes an algorithm that may be used within the prehospital setting. A literature review was conducted to identify articles utilizing ketamine in the prehospital setting. The review was limited to English-language articles identified in Embase (1988-June 2017) and the U.S. National Library of Medicine (1970-June 2017. References of all pertinent articles were also reviewed. Ten articles were identified including 418 patients receiving ketamine for agitation. The most commonly utilized route for administration was intramuscular (IM), with five of the seven IM administration studies using a ketamine dose of 5 mg/kg. Ketamine administered in this fashion was efficacious to achieve proper sedation during transport and did not require repeat dosing. Three studies applied a ketamine protocol to outline dosing and the management of ketamine adverse events. The most common adverse events identified were respiratory-related events and hypersalivation. Ketamine has a role for agitation management in the prehospital setting; however, emergency personnel education and ketamine protocols should be utilized to aid in safe and effective pharmacotherapy and provide guidance on the management of adverse events. Future prospective comparative studies, with protocolized standard ketamine regimens, are needed to further delineate the role of ketamine in agitation management and identify accurate adverse event incidence rates.

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“…We have endeavored ourselves to conduct a similar trial, the results of which were published recently. 2 We are puzzled, however, by several aspects of their methodology that lacked clarity. The authors themselves note patients were enrolled and randomized without their consent, and that patients "met very specific inclusion criteria."…”

mentioning

confidence: 99%