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PSOW 2012 - ExDS and Ketamine

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PSOW 2012 - ExDS and Ketamine

  1. 1. Ketamine for the Control ofthe Agitated and Combative: The Wisconsin Experience Michael D. Curtis, MD, FACEP EMS Medical Director Ministry Health Care Stevens Point, Wisconsin
  2. 2. Objectives Describe the Excited Delirium Syndrome (ExDS) Treatment Triad Describe the characteristic of the ideal drug for controlling agitation State why Ketamine may represent the ideal drug for this purpose Identify lessons learned regarding Ketamine therapy in the setting of ExDS
  3. 3. Excited Delirium Syndrome Agitation Treatment Triad Acidosis Hyperthermia “Treat the Triad!”Source: Chief John Gardner (MDCFR); IPICD Conference – Nov. 2007 Las Vegas
  4. 4. Therapeutic Considerations The first goal of therapy is to gain control of the behavior The second goal of therapy is to stabilize the underlying physiological processes
  5. 5. Drugs Used for Sedation Benzodiazepines • Valium, Versed, Ativan Antipsychotics • Haldol, Droperidol Atypical antipsychotics • Geodon, Zyprexa Dissociative anesthetic agent • Ketamine
  6. 6. Sedation for ExDS Characteristics of an ideal drug • Rapidly effective in a single dose • Minimal adverse effects  Cardiovascular  Respiratory  Neurological  Hyperthermia  Drug interactions
  7. 7. Ketamine for ExDS Very rapid onset of action • (<5 minutes) Highly effective in a single dose Favorable safety profile in healthy patients • Supports heart rate and blood pressure • Preserves respiratory drive • Some neurological concerns Limited data for this indication
  8. 8. The Wisconsin Experience  Portage County  Beloit  Baraboo  Lake Country (Delafield)  Dane County  Eau Claire  Chippewa Falls  Others?
  9. 9. Prehospital Goals of Therapy Quickly and effectively gain compliance with a single dose • 5 mg/kg IM • 2 mg/kg IN ??? • 1-2 mg/kg IV Prevent violent struggle with police and ongoing struggle against restraints Ensure EMS crew safety
  10. 10. Prehospital Goals of Therapy Gain IV access for fluid and medication administration Initiate supportive therapies Transport to the emergency department for definitive evaluation and management Monitor carefully
  11. 11. Profile of Ketamine CasesTime Frame April 2009 through August 2012Number of Cases 36Beloit 20 (Barb & Rick)Portage County 10 (Michael)Lake Country 5 (Lynn and Paul)Chippewa Falls 1 (Justus and Eric)
  12. 12. Profile of Ketamine CasesAge Average: 33.0 (13-81)(*Outliers Removed) Average: 32.3* (17-60)Sex Male: 63%Ethnicity White: 56% Black: 25% Hispanic: 5% Unknown: 14%
  13. 13. Time of Day Differences Frequency of Cases by Time of Day 50%Relative Frequency N = 40% 03--09 30% 09--15 36 20% 15--21 21--03 10% 0% 1 Time of Day
  14. 14. Seasonal Differences Seasonal Variation in CasesRelative Frequency N=36 40% 35% 30% Winter 25% Spring 20% 15% Summer 10% Fall 5% 0% 1 Seasons
  15. 15. Performance DataWere the indications met? 94%Was the correct dosage 86%given?Was the desired control 81%achieved in <5 minutes?Were there any (4) 11%complications due toKetamine?Were there any other (3) 8%unusual occurrences?
  16. 16. Not Indicated Post-op delirium case Postictal psychosis or delirium Hypoglycemic delirium?? When you are up to your ass in alligators, sometimes it’s difficult to remember that your initial objective was to drain the swamp!
  17. 17. Under Dosing The DOC recommended a lower dose • Why did you ask? The MEDIC underestimated the weight. • “No dear, that dress doesn’t make you look fat!” The PATIENT had mostly calmed down already • The fluctuating course of delirium
  18. 18. Ineffective Under dosing How extreme can agitation become? • We have stories to tell…
  19. 19. Adverse Effects “The usual suspects” • Laryngospasm, drooling, nausea and vomiting Worrisome • Possible drug interactions  E.g., EtOH, Narcs, BZDs, Meth, Coc, psych meds, etc. • Intubations  Bellwether of doom for ketamine?  How many would have been tubed anyway?
  20. 20. Unusual Occurrences Elderly man with sun downing Postictal psychosis or delirium.
  21. 21. Discussion Ketamine is indicated for controlling agitated, combative and violent behavior of persons in police custody The goal is a full dissociative state The full dissociative dose is 5 mg/kg IM Two cases of apparent failure were reported
  22. 22. Discussion Paramedics can correctly dose ketamine by protocol Medical control variability may account for some response variability Well known adverse effects of ketamine are observed in low frequency
  23. 23. Discussion Several patients were intubated, which raises several questions… • Does respiratory depression occur when ketamine is combined with alcohol, narcotics, or other CNS depressants? • Can intubation be avoided with careful monitoring and supportive care?
  24. 24. What do you think?
  25. 25. Thank you!