1. Ketamine for the Control of
the Agitated and Combative:
The Wisconsin Experience
Michael D. Curtis, MD, FACEP
EMS Medical Director
Ministry Health Care
Stevens Point, Wisconsin
2. 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
3. Excited Delirium Syndrome
Agitation
Treatment
Triad
Acidosis Hyperthermia
“Treat the Triad!”
Source: Chief John Gardner (MDCFR); IPICD Conference – Nov. 2007 Las Vegas
4. 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
6. Sedation for ExDS
Characteristics of an ideal drug
• Rapidly effective in a single dose
• Minimal adverse effects
Cardiovascular
Respiratory
Neurological
Hyperthermia
Drug interactions
7. 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
8. The Wisconsin Experience
Portage County
Beloit
Baraboo
Lake Country
(Delafield)
Dane County
Eau Claire
Chippewa Falls
Others?
9. 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
10. 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
11. Profile of Ketamine Cases
Time Frame April 2009 through
August 2012
Number of Cases 36
Beloit 20 (Barb & Rick)
Portage County 10 (Michael)
Lake Country 5 (Lynn and Paul)
Chippewa Falls 1 (Justus and Eric)
12. Profile of Ketamine Cases
Age Average: 33.0 (13-81)
(*Outliers Removed) Average: 32.3* (17-60)
Sex Male: 63%
Ethnicity White: 56%
Black: 25%
Hispanic: 5%
Unknown: 14%
13. 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
14. Seasonal Differences
Seasonal Variation in Cases
Relative Frequency N=36
40%
35%
30% Winter
25% Spring
20%
15% Summer
10% Fall
5%
0%
1
Seasons
15. Performance Data
Were 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 to
Ketamine?
Were there any other (3) 8%
unusual occurrences?
16. 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!
17. 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
19. 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?
21. 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
22. 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
23. 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?
