Ketamine for Pre-hospital Control of Agitated Delirious Patients: Promising but Not yet Ready for Prime Time

Providing acute medical care to severely agitated patients in the pre-hospital setting is a significant challenge. These patients often pose a serious safety threat to themselves and emergency medical services (EMS) providers. The dilemma confronting paramedics is they can’t provide medical care until the can restrain the individual and they can’t restrain the individual until they provide sedation. This is a bit reminiscent of the dilemma confronting individuals seeking their first job – you know how the phrase goes. Currently, no real solution to this problem exists. Most agents currently available act too slowly or require establishing an intravenous (IV) line. Of course, if you can establish an IV, you probably don’t need to sedate the patient in the first place. The use of ketamine in the field by paramedics for chemical restraint could be an important new development. This is a relatively new concept, but if it proves safe and effective, it would absolutely change medical practice. This alone makes the article by Scheppke et al. published in this issue of the journal worth reading.1 The authors of this manuscript describe a retrospective chart review of patients who received intramuscular (IM) ketamine for chemical restraint in the field by EMS providers. The study covered a 39-month period and included patients from five different catchment areas who received ketamine solely for chemical restraint in the field per a paramedic protocol (standing order). Researchers abstracted the patients’ pre-hospital medical record looking for specific endpoints. The primary outcome was the adequacy and duration of field sedation. Secondary outcomes included the elapsed time to achieve medical control of patients, any airway or respiratory side effects, and the presence of hemodynamic compromise. The authors conclude that ketamine was both safe and effective in sedating 50 out of 52 patients. The average time to sedation and medical control was just over 2 minutes for the 50 patients successfully sedated. No hemodynamic complications occurred, and paramedics recorded only 3 cases of respiratory University of California, Irvine School of Medicine, Center for Disaster Medical Sciences, Department of Emergency Medicine, Orange, California