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2014 PSOW Ketamine Update
Citation preview
Ketamine for Prehospital Sedation in Excited Delirium
Michael D. Curtis, MD, FACEP
Charles E. Cady, MD, FACEP
Introduction
Acute delirium with violent agitation may lead to sudden unexpected cardiac arrest in previously healthy persons
Struggling during arrest procedures and continued struggle after physical restraints have been applied appear to be major risk factors
What is the ideal therapeutic approach? Remains to be determined Rapid effective tranquilization
IM or IN administration Little or no adverse cardiovascular and
respiratory side effects Facilitates rapidly instituting resuscitative
measures
What is the ideal therapeutic approach? Appropriate supportive therapy
Fluid resuscitation Reversing metabolic acidosis Reversing hyperthermia
Have to control the patient first
Indications
To control agitated and combative behavior Law Enforcement
When the subject is resisting forcefully or continuing to struggle against restraints
EMS When the patient poses a significant threat of
harm to self or others, including the EMS crew
Prehospital Goals of Therapy
Quickly and effectively gain subject/patient compliance with a single dose
Prevent violent struggle with police and ongoing struggle against restraints
Gain IV access for fluid and medication administration
Initiate supportive therapies Transport to the emergency department for
definitive evaluation and management
Dosages
Ketamine 5 mg/kg IM Repeat Dosages
Requires an order from medical control 1 – 2 mg/kg IM 1 mg/kg IV slowly over 60 seconds
Dilute the desired dose of the 100mg/ml formulation with an equal volume of NS or D5W
Incompatible with diazepam in the same syringe
Post-ketamine Sedation
Benzodiazepines Geodon, Zyprexa Haldol, Droperidol
Patient Monitoring and Support
Prevent vomiting with aspiration Mild tachycardia and hypertension are
expected Hypotension and bradycardia occasionally
occur Transient respiratory depression occasionally
occurs Laryngospasm may produce mild stridor
Adverse reactions
Hypertension and tachycardia Hypotension and bradycardia Laryngospasm Hypersalivation Nausea and vomiting Tonic and clonic muscle movements Roving eyes or nystagmus
Psychological Adverse Reactions
Occur in about 12% of patients Ages 15 – 45 Short lived (hours) Preventable with administration of
benzodiazepines Visual Hallucinations Nightmares Emergence Delirium Sensation of detachment from the body
Wisconsin Ketamine Study
Portage County Beloit Eau Claire Lake Country Baraboo Madison Oshkosh Fond du Lac Brown County
Gundersen Tri-State Antigo Wausau Baldwin West Bend De Pere SAFER
Wisconsin Ketamine Study
Froedtert & Medical College of Wisconsin IRB (Institutional Review Board) Approval Any cases prior to September 13, 2013
Extension to 9-30-2014 request pending Principal investigators:
Charles E. Cady, MD – Froedtert-MCW Michael D. Curtis, MD – Ministry Health Care
Wisconsin Ketamine Study
Waivers Informed Consent Waiver
We do not need to obtain informed consent from the participants to enroll them in the study
HIPAA Waiver EMS run reports and related documents can be
shared with the principal investigators
Wisconsin Ketamine Study
Inclusion Criteria Cases in Wisconsin EMS systems Ketamine used to control agitated, combative
or violent behavior In custody of law enforcement Significant threat to self or others, including
emergency responders Adult and pediatric cases Any gender Any race
Wisconsin Ketamine Study
Inclusion Criteria Causes:
Stimulant and other drug abuse Psychiatric disease
New onset Recrudescent disease Psychiatric drug “withdrawal” syndromes
Alcohol intoxication Developmental and cognitive disorders Agitated Dementia
Wisconsin Ketamine Study
Exclusion Criteria Other uses of Ketamine
Pain management Asthma RSI
Other settings Emergency Department HEMS Critical Care Transport ICU OR
Wisconsin Ketamine Study
Exclusion Criteria Other causes
Should we exclude head injury cases with extreme agitation?
Wisconsin Ketamine Study
Procedure All documents should be in pdf format Include:
At a minimum: EMS run reports and any supporting documents
Would be nice: Corresponding ED records At the maximum: Hospital discharge summary
Please keep them grouped together by case
Wisconsin Ketamine Study
Procedure (Cont’d) Let me know via email when you are ready to
send them I will send you a secure email using Data
Motion Attach the records to that email and return
them You may have to do each case separately or
send small groups of cases
Wisconsin Ketamine Study
Procedure (Cont’d) Do not redact any information, like patient
identifiers I will store them all in a password protected file
and password protect the documents I will extract all study data to data forms and
also store them securely I will manage a spreadsheet with all the data
and store it securely I will not print paper copies of any protected
information
Wisconsin Ketamine Study
If I have questions I may contact you I may discuss the cases with Dr. Cady
I will not divulge any protected information to any other persons, except in aggregate form
I will not review these cases for quality of care purposes or provide feedback
Wisconsin Ketamine Study
What we need from you Review our IRB Application and Approval
Decide if you will participate Primary contact, email and phone Protocols, Policies, Procedures Population you serve Geographic area of service coverage
Wisconsin Ketamine Study
What we need from you EMS Run Reports (minimum) ED Records, Discharge Summaries
(maximum) Alternative – Data Collection Form
Wisconsin Ketamine Study
State EMS Office Can you give us a list of services approved to
use Ketamine? Can you help us to distribute notice of the
study to all services in Wisconsin?
Wisconsin Ketamine Study
Our contact information Michael D. Curtis, MD [email protected] 715-498-2240
Charles E. Cady, MD [email protected] 262-501-4880
Questions