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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
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
Excited Delirium Syndrome Agitation Treatment Triad Acidosis Hyperthermia “Treat the Triad!”Source: Chief John Gardner (MDCFR); IPICD Conference – Nov. 2007 Las Vegas
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
Sedation for ExDS Characteristics of an ideal drug • Rapidly effective in a single dose • Minimal adverse effects Cardiovascular Respiratory Neurological Hyperthermia Drug interactions
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
The Wisconsin Experience Portage County Beloit Baraboo Lake Country (Delafield) Dane County Eau Claire Chippewa Falls Others?
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
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
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)
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
Seasonal Differences Seasonal Variation in CasesRelative Frequency N=36 40% 35% 30% Winter 25% Spring 20% 15% Summer 10% Fall 5% 0% 1 Seasons
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?
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!
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
Ineffective Under dosing How extreme can agitation become? • We have stories to tell…
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?
Unusual Occurrences Elderly man with sun downing Postictal psychosis or delirium.
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
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
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?