Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine

Olives, Travis D.; Nystrom, Paul C.; Cole, Jon B.; Dodd, Kenneth W.; Ho, Jeffrey D.

doi:10.1017/s1049023x16000819

Cited by 54 publications

(32 citation statements)

References 35 publications

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“…While not measured as a primary outcome in this study, patients who received ketamine were less likely to be intubated when compared to patients who received benzodiazepines (3.8% vs. 63%, p < 0.001). This is notable as other studies have demonstrated high rates of intubation following ketamine for severe agitation . However, we cannot rule out the presence of confounding factors, such as presentation severity, which may have biased the results toward a particular agent for a given presentation.…”

Section: Discussionmentioning

confidence: 80%

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine

Lebin

Akhavan

Hippe

et al. 2019

Academic Emergency Medicine

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Background: Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.Methods: This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.Results: During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = -2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = -6.8%, 95% CI = -18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = -46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = -33%, 95% CI = -100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001).Conclusions: Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.A cute, undifferentiated agitation is a commonly encountered problem in the prehospital and emergency department (ED) setting. 1,2 When verbal deescalation is ineffective, pharmacologic management may be required to ensure safety for both patients and providers. Traditional pharmacologic treatments for From the

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Section: Discussionmentioning

confidence: 80%

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine

Lebin

Akhavan

Hippe

et al. 2019

Academic Emergency Medicine

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“…Riddell et al ., [ 3 ] showed that only2/23 (8.7%) of ketamine patients were intubated. Olives et al ., [ 25 ] showed that endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. In contrast, in a retrospective study, none of the patients who received emergency treatment to control their agitation needed intubation [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Effect of Intramuscular Ketamine versus Haloperidol on Short-Term Control of Severe Agitated Patients in Emergency Department; A Randomized Clinical Trial

Heydari

Gholamian

Zamani

et al. 2018

BEAT

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Objective:To evaluate the efficacy and safety of intramuscular ketamine and haloperidol in sedation of severely agitated patients in emergency department (ED). Methods: This randomized, double-blind clinical trial study was performed on agitated patients referring to two university educational hospitals. Patients were randomly assigned to receive intramuscular (IM) haloperidol (5 mg) or IM ketamine (4 mg/kg). The primary outcome was time to adequate sedation (AMSS ≤ +1). Secondary outcomes included the need for additional sedatives, required intubation, duration of hospitalization, and side effects. Results:The 90 agitated patients were enrolled. The mean age was 30.37±7.36 years (range 18–56); 74% (67/90) were men. The mean time to adequate sedation in ketamine group (7.73 ± 4.71 minutes) was significantly lower than haloperidol group (11.42 ± 7.20 minutes) (p= 0.005). 15 minutes after intervention, the sedation score did not differ significantly in both groups (Ketamine:0.14 ± 0.59 vs. Haloperidol: 0.30 ± 0.60; p=0.167). The incidence of complications was not significantly different between groups. The physician's satisfaction from the patients’ aggression control was significantly higher in ketamine group. Conclusion:These data suggest ketamine may be used for short-term control of agitated patients, additional studies are needed to confirm if ketamine is safe in this patient population. Given rapid effective sedation and the higher physician satisfaction of ketamine in comparison to haloperidol, it may be considered as a safe and appropriate alternative to haloperidol.IRCT Code: IRCT20180129038549N5

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“…Additional studies have sought to identify the optimal route of ketamine administration, as well as evaluate the use of combined routes of ketamine administration. In a retrospective chart review, intubation rates in 135 patients with excited delirium who received IM (5 mg/kg), IV (2 mg/kg), or IO (2 mg/kg) ketamine via a prehospital ketamine protocol were reported . The objective of this study was to evaluate the incidence of intubation in patients with clinically significant profound agitation and characterize findings from patients who required intubation.…”

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%

“…In a retrospective chart review, intubation rates in 135 patients with excited delirium who received IM (5 mg/kg), IV (2 mg/kg), or IO (2 mg/kg) ketamine via a prehospital ketamine protocol were reported. 25 The objective of this study was to evaluate the incidence of intubation in patients with clinically significant profound agitation and characterize findings from patients who required intubation. Although only four patients in the field required intubation, most patients (85 [63%]) required intubation upon ED arrival.…”

Section: Miscellaneous Ketamine Studiesmentioning

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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Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine

Cited by 54 publications

References 35 publications

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine

Effect of Intramuscular Ketamine versus Haloperidol on Short-Term Control of Severe Agitated Patients in Emergency Department; A Randomized Clinical Trial

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

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