UMEM Educational Pearls

Title: Ketamine for Prehospital Agitation - Prospective Study Results

Keywords: ketamine, agitation, prehospital, haloperidol (PubMed Search)

Posted: 6/7/2016 by Bryan Hayes, PharmD (Emailed: 6/9/2016) (Updated: 6/27/2016)
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Ketamine is gaining traction as a prehospital option for managing severe agitation or excited delirium syndrome. Previous reports have mostly been case series, but a new prospective study adds some important information that may help delineate ketamine's role in this setting. [1] The study and an accompanying commentary are both open access. [2]

What They Did

Open-label before-and-after prospective comparison of haloperidol (10 mg IM) versus ketamine (5 mg/kg IM) for the treatment of acute undifferentiated agitation.

What They Found

Ketamine demonstrated a statistically and clinically significant difference in median time to sedation compared to haloperidol, 5 min vs. 17 min (p < 0.0001, 95% CI: 9 15)
Complications: ketamine, 49%; haloperidol, 5%
- Ketamine complications: hypersalivation (38%), emergence reaction (10%), vomiting (9%), and laryngospasm (5%)
Intubation rate: ketamine, 39%; haloperidol, 4%

Appliation to Clinical Practice

Ketamine works for prehospital agitation (and more rapidly)
Ketamine has a higher complication and intubation rate
Though this study did not find a dose relationship between ketamine and intubations, future studies should evaluate further and potentially use lower ketamine doses
At our institution, we start with 2-3 mg/kg IM and repeat if necessary after 5 min. Most patients have not required a second dose and none have been intubated. This allows time to place an IV line and initiate additional treatment.

References

Cole JB, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol. 2016 Apr 21. Epub ahead of print. [open access PDF]
Hayes BD. Ketamine for agitation: a key cog in the prehospital treatment armamentarium wheelhouse. Clin Toxicol. 2016 May 3. Epub ahead of print. [open access PDF]

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