Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

O’Connor, Laurel; Rebesco, Matthew; Robinson, Conor; Gross, Karen; Castellana, Andrew; O'Connor, Mark J.; Restuccia, Marc C.

doi:10.1080/10903127.2018.1501445

Cited by 20 publications

(17 citation statements)

References 13 publications

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“…In a further retrospective study, it was found that patients who receive ketamine need intubation more frequently, and they also often need haloperidol and benzodiazepines in their further course (27). The two studies just mentioned were published too late to be included in the analysis for the current clinical practice guideline.…”

Section: Ketaminementioning

confidence: 99%

The Use of Rapid Tranquilization in Aggressive Behavior

Hirsch¹,

Steinert²

2019

Deutsches Ärzteblatt International

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ggressive behavior can be considered pathological only when it arises in the context of disease. It is thus not necessarily an indication for medical treatment. Not only emergency medical personnel and psychiatrists, but also family physicians are often confronted with the question of how to treat aggressive behavior. In one study, psychiatric emergencies accounted for 11.8% of all emergency medical interventions outside the hospital. Psychomotor agitation made up 28% of all psychiatric emergencies, second only to alcohol intoxication (33%) (1). Psychomotor agitation in the context of mental illness and intoxication constitutes a medical emergency. Affected patients can injure themselves or others. In a retrospective survey of six German psychiatric hospitals, 1.7 to 5 aggressive attacks per patient-year were reported (2). In one hospital in the federal state of North Rhine-Westphalia, 171 of the 2210 patients admitted within a 1-year period were involved in aggressive attacks, and a total of 441 episodes of aggressive behavior were reported (3). Psychomotor agitation carries the risk of somatic complications, including electrolyte disturbances, rhabdomyolysis, and lactic acidosis (4, 5). The goal of pharmacotherapy is to calm the patient. Amnesia and deep sedation should be avoided in order not to compromise the patient's ability to participate in joint decision-making about further treatment. Deep sedation also puts patients at risk of cardiorespiratory depression, aspiration, and other complications. No data on this topic are available from Germany, but an Australian study has shown that 16 agitated patients who were pharmacologically sedated (9% of the patients so treated) sustained complications such as hypotension and hypoxemia (6). The health-related causes of aggressive behavior include nearly all kinds of mental disorders, and various somatic illnesses as well. In an emergency, the history should be rapidly obtained from someone who has observed the behavior, and an initial, orienting physical examination should be performed. Intoxications, withdrawal syndromes, a postictal state, and rapidly reversible causes such as hypoglycemia should be ruled out (7). The patient's permission for pharmacotherapy should be obtained whenever possible. In Germany, when the patient refuses treatment, the physician must determine whether coercive emergency treatment is permissible and required, as per the concept of a Summary Background: Psychomotor agitation and aggressiveness in the context of mental illness are medical emergencies. In a survey of six German psychiatric hospitals, 1.7 to 5 aggressive attacks per patient-year were reported. If talking to the patient has no calming effect, intervention with drugs is required. In this article, we review the evidence on tranquilizing drugs and discuss clinically relevant ethical and practical questions, e.g., with respect to involuntary medication. Method: This review is based on pertinent articles retrieved by a selective search in MEDLINE, supplemented by a reference sear...

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Section: Ketaminementioning

confidence: 99%

The Use of Rapid Tranquilization in Aggressive Behavior

Hirsch¹,

Steinert²

2019

Deutsches Ärzteblatt International

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“…5 Prior studies have compared the use of intramuscular (IM) ketamine to traditional IM haloperidol and IM benzodiazepines for control of acute agitation. 7,8 Time to sedation with ketamine was significantly faster than haloperidol (five minutes versus seventeen minutes). However, complication rates were significantly higher with ketamine administration than haloperidol alone.…”

Section: Introductionmentioning

confidence: 99%

“…7,9,10 Comparison of intubation rates between ketamine and haloperidol use in acute agitation revealed ketamine had a significantly higher intubation rate than haloperidol and a combination of haloperidol and benzodiazepines. 7,8 Patients who received ketamine were also more likely to require additional chemical sedation and restraint compared to patients who received haloperidol and benzodiazepines. 8 There is some equipoise in the literature regarding whether there is a direct relationship between ketamine dose and subsequent intubation.…”

Section: Introductionmentioning

confidence: 99%

“…7,8 Patients who received ketamine were also more likely to require additional chemical sedation and restraint compared to patients who received haloperidol and benzodiazepines. 8 There is some equipoise in the literature regarding whether there is a direct relationship between ketamine dose and subsequent intubation. In one prior study, patients intubated in the ED following ketamine administration received a mean dose of 6.2mg/kg IM, while patients not intubated had a mean dose of 4.9mg/kg IM.…”

Section: Introductionmentioning

confidence: 99%

“…12 In other studies examining lower dose protocols, intubation rates ranged from four percent to twelve percent. 8,13 Rates of respiratory depression and intubation following varying initial doses of IM ketamine use have not been thoroughly examined. Many current protocols give paramedics standing orders for the administration of 4mg/kg IM dose of ketamine to a maximum dose of 400mg for adults in the prehospital setting.…”

Section: Introductionmentioning

confidence: 99%

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Patient Outcomes Following Ketamine Administration for Acute Agitation with a Decreased Dosing Protocol in the Prehospital Setting

Cunningham

Gross

Broach

et al. 2021

Prehosp. Disaster med.

Self Cite

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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.

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Behavioral health emergencies

Reich¹,

Ng²

2021

Emergency Medical Services

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Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

Cited by 20 publications

References 13 publications

The Use of Rapid Tranquilization in Aggressive Behavior

The Use of Rapid Tranquilization in Aggressive Behavior

Patient Outcomes Following Ketamine Administration for Acute Agitation with a Decreased Dosing Protocol in the Prehospital Setting

Behavioral health emergencies

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