Hostname: page-component-78c5997874-dh8gc Total loading time: 0 Render date: 2024-11-10T08:55:27.960Z Has data issue: false hasContentIssue false
  • English
  • Français

Rescue Intubation in the Emergency Department After Prehospital Ketamine Administration for Agitation

Published online by Cambridge University Press:  14 September 2020

Daniel J. Parks Open the ORCID record for Daniel J. Parks [Opens in a new window] ,
Scott M. Alter Open the ORCID record for Scott M. Alter [Opens in a new window] ,
Richard D. Shih Open the ORCID record for Richard D. Shih [Opens in a new window] ,
Joshua J. Solano Open the ORCID record for Joshua J. Solano [Opens in a new window] ,
Patrick G. Hughes Open the ORCID record for Patrick G. Hughes [Opens in a new window]  and
Lisa M. Clayton Open the ORCID record for Lisa M. Clayton [Opens in a new window]
Daniel J. Parks
Affiliation:
Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA
Scott M. Alter*
Affiliation:
Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA
Richard D. Shih
Affiliation:
Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA
Joshua J. Solano
Affiliation:
Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA
Patrick G. Hughes
Affiliation:
Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA
Lisa M. Clayton
Affiliation:
Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA
*
Correspondence: Scott M. Alter, MD, MBA Florida Atlantic University at Bethesda Health Division of Emergency Medicine GME Suite, Lower Level 2815 South Seacrest Blvd Boynton Beach, Florida33435USA E-mail: alters@health.fau.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

Prehospital intramuscular (IM) ketamine is increasingly used for chemical restraint of agitated patients. However, few studies have assessed emergency department (ED) follow-up of patients receiving prehospital ketamine for this indication, with previous reports suggesting a high rate of post-administration intubation. This study examines the rate of and reasons for intubation and other airway interventions in agitated patients who received ketamine by Emergency Medical Services (EMS).

Methods:

This retrospective cohort study included patients who received prehospital ketamine for agitation and were transported to two community hospital EDs. Charts were reviewed for demographics, ketamine dose, and airway intervention by EMS or in the ED. Characteristics of patients who were intubated versus those who did not receive airway intervention were analyzed.

Results:

Over 28 months, 86 patients received ketamine for agitation. Fourteen (16.3%) underwent endotracheal intubation. Patients with a higher temperature and a lower Glasgow Coma Score (GCS) were more likely to require intubation. There was no age or dose-dependent association on intubation rate. Intubated patients averaged 39 years old versus 44 for patients not intubated (negative five-year difference; 95% CI, -16 to 6). The mean ketamine dose was 339.3mg in patients intubated versus 350.7mg in patients not (-11.4mg difference; 95% CI, -72.4 to 49.6). The mean weight-based ketamine dose was 4.44mg/kg in patients intubated versus 4.96mg/kg in patients not (-0.53mg/kg difference; 95% CI, -1.49 to 0.43).

Conclusions:

The observed rate of intubation in patients receiving prehospital ketamine for agitation was 16.3%. Study data did not reveal an age or dose-dependent rate of intubation. Further research should be conducted to compare the airway intervention rate of agitated patients receiving ketamine versus other sedatives in a controlled fashion.

Keywords

airway managementdeliriumintubationketaminepsychomotor agitation
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 35 , Issue 6 , December 2020 , pp. 651 - 655
Check for updates
Copyright
© The Author(s), 2020. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Scaggs, TR, Glass, DM, Hutchcraft, MG, Weir, WB. Prehospital ketamine is a safe and effective treatment for excited delirium in a community hospital-based EMS System. Prehosp Disaster Med. 2016;31(5):563–569.CrossRefGoogle Scholar
Zun, LS. Evidence-based review of pharmacotherapy for acute agitation. Part 2: Safety. J Emerg Med. 2018;54(4):522–532.Google ScholarPubMed
Linder, LM, Ross, CA, Weant, KA. Ketamine for the acute management of excited delirium and agitation in the prehospital setting. Pharmacotherapy. 2018;38(1):139–151.CrossRefGoogle ScholarPubMed
Burnett, AM, Peterson, BK, Stellpflug, SJ, et al. The association between ketamine given for prehospital chemical restraint with intubation and hospital admission. Am J Emerg Med. 2015;33(1):76–79.Google ScholarPubMed
Cole, JB, Moore, JC, Nystrom, PC, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol (Phila). 2016;54(7):556–562.Google ScholarPubMed
Olives, TD, Nystrom, PC, Cole, JB, Dodd, KW, Ho, JD. Intubation of profoundly agitated patients treated with prehospital ketamine. Prehosp Disaster Med. 2016;31(06):593–602.Google ScholarPubMed
Mankowitz, SL, Regenberg, P, Kaldan, J, Cole, JB. Ketamine for rapid sedation of agitated patients in the prehospital and emergency department settings: a systematic review and proportional meta-analysis. J Emerg Med. 2018;55(5):670–681.Google ScholarPubMed
Cole, JB, Klein, LR, Nystrom, PC, et al. A prospective study of ketamine as primary therapy for prehospital profound agitation. Am J Emerg Med. 2018;36(5):789–796.Google ScholarPubMed
Keseg, D, Cortez, E, Rund, D, Caterino, J. The use of prehospital ketamine for control of agitation in a metropolitan firefighter-based EMS system. Prehosp Emerg Care. 2015;19(1):110–115.CrossRefGoogle Scholar
Hollis, GJ, Keene, TM, Ardlie, RM, Caldicott, DG, Stapleton, SG. Prehospital ketamine use by paramedics in the Australian Capital Territory: a 12-month retrospective analysis. Emerg Med Australas. 2017;29(1):89–95.CrossRefGoogle ScholarPubMed
Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, Conde, JG. Research Electronic Data Capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.Google ScholarPubMed
Scheppke, KA, Braghiroli, J, Shalaby, M, Chait, R. Prehospital use of IM ketamine for sedation of violent and agitated patients. West J Emerg Med. 2014;15(7):736–741.CrossRefGoogle Scholar
Isbister, GK, Calver, LA, Downes, MA, Page, CB. Ketamine as rescue treatment for difficult-to-sedate severe acute behavioral disturbance in the emergency department. Ann Emerg Med. 2016;67(5):581-587.e1.Google ScholarPubMed