“Experts” call for conversation about forced ketamine use/ forced sedation

[alpinism]

I'd like to point out that based on the literature high doses of ketamine are extremely safe when given to agitated patients.

Ketamine is not the same as other sedatives and should not be dosed on an incremental basis. Perhaps the most most common mistake I often see with colleagues is attempting to give it in multiple small doses. This often leads to partial dissociation and worsens agitation in some patients. If you have an acutely agitated patient you want them put down as quickly and as safely as possible which is giving a single 5 mg/kg IM dose.

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[oldiebutgoodie1211]

1. Cool. You're the expert.

2. Thought I read an article at some point somewhere saying '2 MIs in route'. That's what I was referring too and yeah it appears layperson misinterpretation. So yeah, you're right.

3. Agree. OP could've concluded that without specialty bashing. To each their own.

you’re an anesthesiologist, the be all end all sedation pharm expert, you’re really gonna let the triage doctor who couldn’t explain the mechanisms of action to save his life, talk to you like that? Damn now I see why nurses are taking over your field..

 

[TwoHighways]

you’re an anesthesiologist, the be all end all sedation pharm expert, you’re really gonna let the triage doctor who couldn’t explain the mechanisms of action to save his life, talk to you like that? Damn now I see why nurses are taking over your field..

Shots fired! Tell us how you really feel haha

 

[AMEHigh]

I'd like to point out that based on the literature high doses of ketamine are extremely safe when given to agitated patients.

Ketamine is not the same as other sedatives and should not be dosed on an incremental basis. Perhaps the most most common mistake I often see with colleagues is attempting to give it in multiple small doses. This often leads to partial dissociation and worsens agitation in some patients. If you have an acutely agitated patient you want them put down as quickly and as safely as possible which is giving a single 5 mg/kg IM dose.

I’m genuinely asking since I’m not EM, but is the safety of ketamine researched in more controlled settings like the hospital or also out of hospital settings? It seems like it would make a difference when giving certain medications after someone has been slammed to the ground, in a choke hold, etc.

It seems like there’s a difference between agitation because someone is having a mental health "break down" vs when someone is agitated because they’re handcuffed and someone has them in a choke hold.

It definitely seems like a review of these protocols is not a bad thing.

 

[TwoHighways]

That’s great and will serve you well. We have much greater experience though having been through medical school and residency, as well as having practiced as attendings. Please be careful in sharing clinical opinions without disclosing how your background at the same time informs your views, otherwise it implies you are a practicing EP, when in reality that is far from the case.

Nobody should take anyone’s opinions posted online through an anonymous medium without a huge grain of salt, physician or not, but I’ll keep your concerns in mind.

 

[calvnandhobbs68]

Why am I not seeing as much in this thread to use what we actually use for agitated patients all the time? 5mg Haldol + 50mg Benadryl IM makes most of the population relax pretty quick and heads off dystonic sx. Alternatively 10mg of Zyprexa IM makes you sleepy real fast. Why even give something with the side effect profile of ketamine in the first place when we give this stuff all the time with much less concern about possible side effects?

 

[thegenius]

you’re an anesthesiologist, the be all end all sedation pharm expert, you’re really gonna let the triage doctor who couldn’t explain the mechanisms of action to save his life, talk to you like that? Damn now I see why nurses are taking over your field..

 

[thegenius]

Why am I not seeing as much in this thread to use what we actually use for agitated patients all the time? 5mg Haldol + 50mg Benadryl IM makes most of the population relax pretty quick and heads off dystonic sx. Alternatively 10mg of Zyprexa IM makes you sleepy real fast. Why even give something with the side effect profile of ketamine in the first place when we give this stuff all the time with much less concern about possible side effects?

I was thinking the same thing. I commonly give 5-2-1 (haldol 5 IM, ativan 2 IM, cogentin 1 IM) which is the "STFU" or "CTFD" dose.

But the whole purpose of this thread, prior to all the bashing and punching and poo-flinging that just about every thread on SDN EM turns into.....is that police should not be sedating people with ketamine at all, and EMS should do it only after sufficient training and they should all have appropriate rescue meds and equipment if they do that.

Remember I never sedate someone and walk away, they are always monitored by equipment and nurses.

 

[WilcoWorld]

you’re an anesthesiologist, the be all end all sedation pharm expert, you’re really gonna let the triage doctor who couldn’t explain the mechanisms of action to save his life, talk to you like that? Damn now I see why nurses are taking over your field..

I'd be happy to explain the (currently best supported theoretical) mechanism of action of all the meds I use commonly in the ED.

 

[oldiebutgoodie1211]

Why am I not seeing as much in this thread to use what we actually use for agitated patients all the time? 5mg Haldol + 50mg Benadryl IM makes most of the population relax pretty quick and heads off dystonic sx. Alternatively 10mg of Zyprexa IM makes you sleepy real fast. Why even give something with the side effect profile of ketamine in the first place when we give this stuff all the time with much less concern about possible side effects?

haldol/Ativan is superior to haldol/Benadryl with equal outcomes in terms of EPS

 

[calvnandhobbs68]

haldol/Ativan is superior to haldol/Benadryl with equal outcomes in terms of EPS

I’m personally with most people in the B-52 regimen (50-5-2 Benadryl-haldol-ativan), only concern with the IM ativan in the field is respiratory depression depending on what someone’s intoxicated on (which is probably pretty difficult to figure out on the fly in the field). There’s very little downside to adding the Benadryl and I’ve seen enough dystonic reactions without it to just make it a rule most of the time.

I also agree though with prior posts too that police or people who can’t do monitoring post administration should never be giving any of this stuff. It should be paramedics who then put the patient in an ambulance for monitoring as soon as they can safely get in there.

 

[SamtheWise]

This is a tough topic, forced sedation and evaluation. Anyone who has ever seen an excited delirium arrest knows these patients need to be safely sedated as quickly and cleanly as possible, and some of these patients could be killed by police if not safely sedated. I don't think anesthesiologists are the experts in pre-hospital sedation, just as I am not an expert in intra-operative sedation, and I think this conversation is best had in person with our law makers, fire, EMS and law enforcement colleagues, not on an anonymous forum with medical students who know nothing trying to sound smart and trolls trying to upset everyone.

 

[SamtheWise]

Also b-52 sucks, the benadryl causes a fair amount of respiratory depression and unnecessarily prolongs sedation in my experience, I just give 5 haldol and 2 of ativan, or 5 haldol and 4 midazolam if they need to be put down quicker, I like a little benzo up front to take the edge off while the haldol kicks in.

 

[southerndoc]

I’m genuinely asking since I’m not EM, but is the safety of ketamine researched in more controlled settings like the hospital or also out of hospital settings? It seems like it would make a difference when giving certain medications after someone has been slammed to the ground, in a choke hold, etc.

It seems like there’s a difference between agitation because someone is having a mental health "break down" vs when someone is agitated because they’re handcuffed and someone has them in a choke hold.

It definitely seems like a review of these protocols is not a bad thing.

Yes, there are studies. Many with high intubation rates. Our own data shows a lot of unnecessary head CT's were ordered.

 

[pkwraith]

I have the opposite problem at my shop. EMS brings in an agitated, dissociating patient.
"We gave him ketamine"
"1 mg/kg"
"IM? That's too low"
"We're not allowed to give higher than that."

and they're surprised that the ketamine didn't work, or the patient is now more agitated.

 

[The Knife & Gun Club]

The poo flinging in this thread is ridiculous, especially considering that was actually said in the articles.

The anesthesiologists from article 1 had a very measured, well thought out take in saying that we should probably evaluate use of ketamine in the out of hospital setting. I think all the EPs here would agree it’s not a medication to be given by a non-physician without adequate training. I’ve seen enough little old ladies snowed into oblivion with EMS administered 500mg IM ketamine to know that there’s certainly some paramedics out there who have confused “relatively safe” with “absolutely safe, give as much as you want”

And article 2, while annoying, is completely besides the point. It’s just some BS non-clinician psychologist pontificating and trying to earn some SJW internet points.

The much bigger question here is why a carotid choke hold is acceptable in a guy who (at least based on these articles) does not sound like he required such aggressive physical restraint.

 

[TwoHighways]

Would be interesting to have an open and honest discussion with all parties involved (cop, paramedic, the deceased), but this is the internet and all we can do is speculate and jump to the worst possible conclusions, because that’s what we do best.

 

[Dr Mantis Toboggan]

The poo flinging in this thread is ridiculous, especially considering that was actually said in the articles.

The anesthesiologists from article 1 had a very measured, well thought out take in saying that we should probably evaluate use of ketamine in the out of hospital setting. I think all the EPs here would agree it’s not a medication to be given by a non-physician without adequate training. I’ve seen enough little old ladies snowed into oblivion with EMS administered 500mg IM ketamine to know that there’s certainly some paramedics out there who have confused “relatively safe” with “absolutely safe, give as much as you want”

And article 2, while annoying, is completely besides the point. It’s just some BS non-clinician psychologist pontificating and trying to earn some SJW internet points.

The much bigger question here is why a carotid choke hold is acceptable in a guy who (at least based on these articles) does not sound like he required such aggressive physical restraint.

what scenarios have you seen where EMS gave elderly women that much ketamine? Struggling to come up with an appropriate one? Hip fracture maybe, if they don’t have fentanyl?

 

[alpinism]

I’m genuinely asking since I’m not EM, but is the safety of ketamine researched in more controlled settings like the hospital or also out of hospital settings? It seems like it would make a difference when giving certain medications after someone has been slammed to the ground, in a choke hold, etc.

It seems like there’s a difference between agitation because someone is having a mental health "break down" vs when someone is agitated because they’re handcuffed and someone has them in a choke hold.

It definitely seems like a review of these protocols is not a bad thing.

Rebel EM has a list of all the studies: The Evolution of Ketamine for Severe Agitation - REBEL EM - Emergency Medicine Blog

 

[WilcoWorld]

Tangential anecdote: I had my 1st case of ketamine-associated laryngospasm this weekend. Patient did fine and I think it was helpful that I was able to recognize it early with capnography and thus take action before he got unstable. I'd used ketamine without problems so many times that I was starting to think of laryngospasm as more of a theoretical risk but this weekend I was relieved of that illusion.

I'll still use ketamine with confidence going forward, but I'll be less likely to roll my eyes internally when a med student worries about laryngospasm.

 

[thegenius]

Tangential anecdote: I had my 1st case of ketamine-associated laryngospasm this weekend. Patient did fine and I think it was helpful that I was able to recognize it early with capnography and thus take action before he got unstable. I'd used ketamine without problems so many times that I was starting to think of laryngospasm as more of a theoretical risk but this weekend I was relieved of that illusion.

I'll still use ketamine with confidence going forward, but I'll be less likely to roll my eyes internally when a med student worries about laryngospasm.

How old was the patient? What did you do?

 

[The Knife & Gun Club]

what scenarios have you seen where EMS gave elderly women that much ketamine? Struggling to come up with an appropriate one? Hip fracture maybe, if they don’t have fentanyl?

yea hip fracture and agitated delirium.

 

[SamtheWise]

Tangential anecdote: I had my 1st case of ketamine-associated laryngospasm this weekend. Patient did fine and I think it was helpful that I was able to recognize it early with capnography and thus take action before he got unstable. I'd used ketamine without problems so many times that I was starting to think of laryngospasm as more of a theoretical risk but this weekend I was relieved of that illusion.

I'll still use ketamine with confidence going forward, but I'll be less likely to roll my eyes internally when a med student worries about laryngospasm.

I've seen a couple actually, I'm a black cloud for them. You can break them with basically an aggressive jaw thrust sometimes, but twice I've had to RSI them. I think there's some anesthesia literature about 'half dose paralytics' but that's not something I see myself really ever trying.

 

[suckstobeme]

Tangent:
Do you automatically bill critical care when you use Ketamine for agitation?

 

[WilcoWorld]

Tangent:
Do you automatically bill critical care when you use Ketamine for agitation?

Automatically? No.
Almost always? Yes.

If I do not have any concern for a life threatening condition, then I am not going to be sedating someone with IM ketamine for a work up.

 

[suckstobeme]

Good question that I don’t know the exact answer to. Some have told me that they do just because it is a higher risk situation. Per MedData you can for GCS of 12 or less. I typically don’t. I usually don’t feel the patient has a condition that is life or limb threatening, that without intervening it will lead to the patient having clinically significant deterioration, nor that the intervention of sedation prevents any deterioration. If a patient is severely intoxicated to the point that they are agitated/combative, but also not protecting their airway and end up needing intubation, then I would bill critical care. Most of the time that isn’t the case though. Technically we justify chemical restraint to prevent someone from harming themselves or others, and so there is an argument you could make. I’m curious as well what others think or do.

Automatically? No.
Almost always? Yes.

If I do not have any concern for a life threatening condition, then I am not going to be sedating someone with IM ketamine for a work up.

I have a much lower threshold for going to Ketamine than Wilco... even if they don't need a workup and they are a danger to themselves or others, they are likely going to get ketamine. I think the Ketamine alone is justification for critical care with or without the other workup or concern for another serious medical problem. I think it's like SVT for me. If someone has an SVT and I get them to convert with vagal maneuvers, then I'm probably not doing critical care. If I push adenosine, then I bill critical care. Agitation that I can talk down or use haldol/ativan and get control isn't critical care. If the pt gets ketamine (which my RNs tell me is an "anesthetic agent" and requires an MD to inject), and then I have to do monitoring, check his airway repeatedly, etc etc, then I think critical care is justified. I would say I do critical care on like 90% of my ketamine patients, though certainly I have wondered whether that's OK. I think it is.

 

[Arch Guillotti]

Tangential anecdote: I had my 1st case of ketamine-associated laryngospasm this weekend. Patient did fine and I think it was helpful that I was able to recognize it early with capnography and thus take action before he got unstable. I'd used ketamine without problems so many times that I was starting to think of laryngospasm as more of a theoretical risk but this weekend I was relieved of that illusion.

I'll still use ketamine with confidence going forward, but I'll be less likely to roll my eyes internally when a med student worries about laryngospasm.

What was the dose and the route of administration? Were there excess secretions?

 

[Arch Guillotti]

I've seen a couple actually, I'm a black cloud for them. You can break them with basically an aggressive jaw thrust sometimes, but twice I've had to RSI them. I think there's some anesthesia literature about 'half dose paralytics' but that's not something I see myself really ever trying.

Why not just break the laryngospasm instead of intubating them?

 

[thegenius]

I've seen a couple actually, I'm a black cloud for them. You can break them with basically an aggressive jaw thrust sometimes, but twice I've had to RSI them. I think there's some anesthesia literature about 'half dose paralytics' but that's not something I see myself really ever trying.

Yea I wonder if you just crank up the HFNC and jaw thrust and maybe you can get out of it.

But I bet it's extremely scary and moving to intubate makes sense.

Half dose paralytics? So like overcoming the laryngospasm but not enough to paralyze them? interesting concept.

 

[thegenius]

Why not just break the laryngospasm instead of intubating them?

How you do you that

 

[SamtheWise]

Why not just break the laryngospasm instead of intubating them?

It was a combination of laryngospasm, secretions (despite glyco admin) and mental status from concomitant administration of other other sedatives pre-hospital. Tough airways, bloody from pre-hospital npa placement, swollen and full of secretions.

How you do you that

pressure at 'larson's point' as you jaw thrust is what is classically described, which works pretty well usually unless they have a really poor mental status and tons of secretions, at least in my experience. I've never done half dose paralytics, and doubt I ever will, I just don't think I could estimate someone's weight accurately enough in that moment to be able to appropriately dose it, and would be nervous abut dropping their respiratory drive but not paralyzing enough to actually take the airway if need be. I personally feel like paralytics are all or nothing.

But none of this is to criticize pre-hospital management of these patients, if someone's unsafe sometimes paramedics gotta do what they gotta do, I still feel like respiratory failure and a tube is better than an excited delirium arrest from being held down by 10 people or being shot by the police.

 

[Arch Guillotti]

Half dose paralytics? So like overcoming the laryngospasm but not enough to paralyze them? interesting concept.

I don't know about "half-dose" paralytics but a smidge of sux will break laryngospasm, say 10 or 20 mg. They will probably need respiratory support briefly though.

 

[RoyBasch]

Tangential anecdote: I had my 1st case of ketamine-associated laryngospasm this weekend. Patient did fine and I think it was helpful that I was able to recognize it early with capnography and thus take action before he got unstable. I'd used ketamine without problems so many times that I was starting to think of laryngospasm as more of a theoretical risk but this weekend I was relieved of that illusion.

I'll still use ketamine with confidence going forward, but I'll be less likely to roll my eyes internally when a med student worries about laryngospasm.

I have been told by everyone that ketamine laryngospasm is extremely rare (like 1 in 10,000+) but my experience suggests it's much higher than that. I know very unscientific. However, I have encountered it twice in my career, and probably used ketamine less than 100 times. Almost every physician I have spoken to has encountered it as well, so I think maybe not as rare as we think. Not an absolute contraindication of course, but just have to be ready for it. It is scary when it happens.

I use ketamine for excited delirium (as opposed to procedural sedation) as a second line agent. First line is 5250 (haldol, ativan, benadryl), which drops people 95% of the time so, I do not use ketamine as much.

 

[Arch Guillotti]

I have been told by everyone that ketamine laryngospasm is extremely rare (like 1 in 10,000+) but my experience suggests it's much higher than that. I know very unscientific. However, I have encountered it twice in my career, and probably used ketamine less than 100 times.

What dose and route matters. Personally I have a hard time believing that ketamine itself causes laryngospasm. Depending on the dose ketamine can cause problems with secretions which could irritate the laryngeal musculature and potentially cause laryngospasm though. I have seen an awake person attempt to laryngospasm with incomplete topicalization with local anesthetic so it can certainly occur with blood or secretions in an altered plane of consciousness.

 

[RoyBasch]

What dose and route matters. Personally I have a hard time believing that ketamine itself causes laryngospasm. Depending on the dose ketamine can cause problems with secretions which could irritate the laryngeal musculature and potentially cause laryngospasm though. I have seen an awake person attempt to laryngospasm with incomplete topicalization with local anesthetic so it can certainly occur with blood or secretions in an altered plane of consciousness.

The two times I encountered it: once was IV slow push for a procedural sedation 1mg/kg. The second time was IM 5mg/kg for excited delirium after failure of multiple first line meds.

I did not topicalize the airway in either case.

The cases are fading to memory so I cannot remember if there were excessive issues with secretions, but this certainly may have played a role.