Resident Eagle: EMS and Ketamine—Does It Have a Place?

The prehospital administration of ketamine for excited delirium has been a hot topic for the lay press lately. What should EMS medical directors and chiefs do to educate their local population, local leaders, and local media about the truth regarding this condition and the use of ketamine?

At EMS World Spring, Paul Pepe, MD, MPH, medical director for the Dallas County Emergency Medical Services/Public Safety in Dallas, led a roundtable to discuss ketamine in prehospital use. An excerpt of the session follows.

Kenneth Scheppke, MD, state EMS medical director and chief medical officer, Florida Department of Health and Palm Beach County Fire Rescue:

Ketamine is a fantastic medication for prehospital use. It’s the “Swiss Army knife” of medications. In the prehospital environment we don’t have access to an entire pharmacy, so to have one drug that has multiple indications is fantastic for EMS, and it is quite safe. 

We had significant exposure to this problem of excited delirium with our flakka epidemic in South Florida about 10 years ago. We literally had dozens of patients who became acutely psychotic, hyperthermic, hypermetabolic, and violent. What we found was that we needed to get these patients under control really quickly, and ketamine was quite useful for that. Back then Tasers were being blamed for killing these folks. It wasn’t the Tasers, and it wasn’t the ketamine. It’s the underlying condition itself that causes hypermetabolism and severe metabolic acidosis, and these people are in a pre-cardiac arrest condition. I would argue that ketamine, because of its ability to rapidly get the patient to stop fighting and allow us to put them supine on a stretcher, is actually lifesaving.

Chris Colwell, MD, chief of emergency medicine, Zuckerberg San Francisco General Hospital and Trauma Center:

This is an incredibly important medication for a number of different areas we face in both the prehospital environment and emergency department. One of the most challenging situations we face for which this is the medication of choice is severe agitation (some use the term agitated delirium, others use excited delirium). This is a clinical situation of severe agitation that needs to be managed. It represents a significant threat to healthcare providers but, more important, a life threat to our patients. This is a lifesaving medication when used in those situations. With the proper indications and proper dosages, this is a very safe and effective medication and an important one for us to use.

Sophia Dyer, MD, medical director, Boston EMS:

I agree with others on using the term undifferentiated emergencies. We don’t necessarily know if it’s a psychiatric emergency, drug-induced, or something else. One of the advantages of ketamine is that it has a very rapid onset. So for the right type of situation and appropriate dosing, this is a good medication option. 

Ketamine has real advantages for the “shocky” patient as well, because it doesn’t have the effects on blood pressure of some of our other sedation medications. This is most important for 
systems using it as one of the sedation meds for an RSI program. Ketamine has a benefit for the asthmatic patient as well.

Remle Crowe, PhD, NREMT, research scientist, ESO:

Looking at about 40,000 patients who had an undifferentiated behavioral emergency with documented combativeness, we saw that about 15% received emergent IM sedation. It’s important to put these numbers into context and recognize that ketamine is not just being used for sedation. A much larger proportion of patients was given ketamine for pain.

Stein Bronsky, MD, medical director, Colorado Springs Fire Department, American Medical Response (AMR), El Paso County, Colo., and El Paso-Teller County 9-1-1 Authority:

In Colorado we use ketamine for all the indications mentioned by Dr. Scheppke, and by far the most is for pain management. Recently we had a high-profile case where someone was in extreme agitation (the way Colorado defines that agitation state), and there were some questions raised in the media—one was whether law enforcement was directing the medical professional—and also questions about the dosing and the postadministration management and evaluation of the patients. What’s resulted is that we had a Denver metro area council that set the precedent nationwide for legislating medical practice by stopping the use of ketamine in their particular city. That is a very dangerous precedent because medical professionals like us should be the ones deciding on medical practices. People need to be aware this can happen. We all need to be prepared for political entities coming down the pipeline and potentially shouldering their way into legislating medical practice.

Mike Levy, MD, medical director, Anchorage Fire Department, Alaska Emergency Services, and multiple EMS agencies in Alaska:

If we look at the science and constrain it to the science, we can overwhelmingly state this drug can be used safely and is used safely. Ketamine has a wide safety profile, and if we look at alternatives to deal with the kinds of conditions we see, it’s hard to come up with a drug that gives us as much use, flexibility, and safety as ketamine does. 

The problem is that we do not get to operate in the field of our own choosing. What we do can be “lensed” in different ways, depending on how it’s presented, in particular to the public. It puts our practice at risk. The simple fact is that ketamine is safely used when done so under the aegis of involved medical directors. This is the practice of EMS medicine. The public has reasonable concerns.