Use of intramuscular ketamine by paramedics in the management of severely agitated patients

Abstract

Objective Administration of a sedative agent is required for safe transport of prehospital patients with severe agitation to EDs. Ambulance services in Australasia use ketamine, droperidol or midazolam as first line agent but the optimal agent is uncertain. In Victoria, intramuscular (IM) ketamine is used. The present study aimed to examine the prehospital characteristics and ED outcomes of patients with severe agitation after IM ketamine administration. Methods A retrospective review was conducted for patients who received IM ketamine for severe agitation over a 2‐year period. Data were sourced from Ambulance Victoria and linked to hospital data. The primary outcome was time to sedation. Data collected included baseline characteristics, adverse events and ED outcomes. Results Three hundred and fifty‐eight prehospital cases transported to 32 hospitals were included. Outcome data were available for 305 patients (21 hospitals). Median age was 31 years (IQR 23–40). 71.2% were male. Adequate sedation was achieved in 96.9% of cases in a median time of 5.0 min (IQR 3.0–7.0; range 1–31 min). Adverse events were transient hypoxia (5.0%), hyper‐salivation (4.2%) and emergence reactions (0.8%). A total of 45 (14.8%) patients were intubated; two prehospital. Conclusion Intramuscular ketamine is effective with a low rate of prehospital complications in severely agitated patients in the prehospital setting. Given the variation in ambulance practice in Australasia, prospective, randomised trials in the prehospital setting comparing ketamine to other sedating agents such as droperidol in patients with severe agitation are required.

Intramuscular Ketamine Effect on Postnasal Surgery Agitation: A Prospective Double-Blinded Randomized Controlled Trial

“…In a study on the effect of intramuscular ketamine as a sedative agent on severely agitated patients in the emergency department, the results were inconclusive as to its dose that may produce dissociation, which was already established as 3-4 mg/kg [ 14 ]. Intramuscular ketamine at a dose of <5 mg/kg provides adequate sedation with a low risk for intubation [ 15 ], but a dose of 4 mg/kg was effective in producing sedation for severe agitation but with an increased risk of intubation [ 16 ]. Reducing the dose to 2 mg/kg, O'Brien et al [ 17 ] reported that intramuscular ketamine caused adequate sedation and was effective for severe agitation without the need for intubation.…”