Patients with excited delirium who are combative, aggressive, or agitated before being transported to a hospital or emergency department require immediate treatment for their safety and the safety of others. In the past, physical restraint was the predominant method used to control a patient during transport. However, due to safety concerns, prehospital ketamine – a strong sedative – is now commonly used to control patients with excited delirium. Emergency medical providers usually give ketamine intramuscularly, which takes about three to four minutes.
Ketamine is safe and well tolerated when administered in a controlled environment such as a hospital for procedural sedation, as patients rarely lose their airways or respiratory pulse. Although the use of ketamine is widespread, the evidence for safety and efficacy is limited and the risk factors for respiratory arrest and intubation have not been well studied. In addition, many patients with excited delirium are intoxicated or consume illicit substances and these co-ingestants can alter the properties of the drug.
Researchers at Florida Atlantic University’s Schmidt College of Medicine conducted a study to determine whether patients treated with prehospital ketamine for excited delirium with concomitant substance poisoning have higher subsequent intubation rates in the ward. emergencies compared to those without confirmed substance use.
Study results, published in the journal Prehospital and disaster medicine, showed that among 86 patients who received prehospital intramuscular ketamine for excited delirium, those with concomitant cocaine intoxication had a statistically significant subsequent intubation rate 5.75 times higher in men than in women . No deaths have been reported.
Patients who tested positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates and synthetic cathinones, both bath salts and flakka, had intubation rates similar to those negative for these substances. Baseline characteristics including age, ketamine dose, and body mass index were similar between those who had and had not been intubated.
“Although more research is needed, it is tempting to speculate on possible mechanisms by which prehospital ketamine administered intramuscularly for excited delirium with concomitant cocaine intoxication may increase subsequent intubation in the emergency department.” said Joshua J. Solano, MD, lead author, an emergency physician, assistant professor of emergency medicine and integrated medical sciences, and director of quality improvement and patient safety, FAU Schmidt College of Medicine. “A plausible explanation is that cocaine can deplete excitatory neurotransmitters and cause exaggerated respiratory depression requiring intubation. ”
During the 28 months, all medical records from two large community hospitals were searched for all patients 18 years of age or older who received intramuscular administration of ketamine for excited delirium and identified co-ingestions of illicit substances and on prescription.
For the study, trained abstractors collected demographic characteristics, history of current disease, urine drug tests, alcohol levels, and noted additional sedative administrations. Substance intoxication was determined by urine drug tests and the positivity or negativity of alcohol, as well as a medical history of current illness. Patients without toxicological testing or documentation of substance intoxication, or who could have tested positive due to sedation in the emergency department, were excluded from relevant analyzes. Subsequent intubation in the emergency department was the primary predefined outcome.
Study co-authors are Lisa M. Clayton, DO, emergency physician, associate professor of integrated medical sciences and program director of the FAU emergency medicine residency; Daniel J. Parks, MD, resident physician, FAU emergency medicine; Shayne E. Polley, MD, FAU Medical School graduate and emergency medicine resident at Christ Emergency Medicine in Oak Lawn, Illinois; Patrick G. Hughes, DO, emergency physician, deputy director of the FAU emergency medicine residency program and associate professor of integrated medical sciences; Charles H. Hennekens, MD, Dr. PH, Professor Sir Richard Doll and Senior Academic Advisor; Richard D. Shih, MD, emergency physician, professor of integrated medical sciences and division director of the FAU emergency medicine residency program; and senior author Scott M. Alter, MD, MBA, emergency physician, associate professor of emergency medicine and associate research director of the FAU emergency medicine residency, all at Schmidt College of Medicine.
– FAU –
About Charles E. Schmidt College of Medicine:
The Charles E. Schmidt College of Medicine at FAU is one of approximately 155 accredited medical schools in the United States. The college was launched in 2010, when the Florida Board of Governors made a landmark decision authorizing the FAU to award the medical degree. After receiving the approval of the Florida legislature and governor, it became the 134th school of allopathic medicine in North America. With more than 70 full and part-time professors and more than 1,300 affiliated professors, the college enrolls 64 medical students each year and has been recognized nationally for its innovative curriculum. In order to strengthen the FAU’s commitment to increase much needed medical residency positions in Palm Beach County and to ensure that the region continues to have an adequate and well-trained medical workforce, the FAU Charles E. Schmidt College of Medicine Consortium for Graduate Medical Education (GME) was formed in the fall of 2011 with five major Palm Beach County hospitals. The consortium currently has five residences accredited by the Accreditation Council for Higher Medical Education (ACGME), including internal medicine, surgery, emergency medicine, psychiatry and neurology.
About Florida Atlantic University:
Florida Atlantic University, established in 1961, officially opened in 1964 as Florida’s fifth public university. Today, the University welcomes more than 30,000 undergraduate and graduate students at six campuses located along the Southeast Florida coast. In recent years, the University has doubled its research spending and surpassed its peers in student success rates. Through the coexistence of access and excellence, FAU embodies an innovative model where traditional success gaps disappear. The FAU is named as a Hispanic-focused institution, ranked among the top public universities by US News & World Report, and a high-research institution by the Carnegie Foundation for the Advancement of Teaching. For more information visit www.fau.edu.
Prehospital and disaster medicine
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Prehospital administration of ketamine for excited delirium with co-ingestion of illicit substances and subsequent intubation in the emergency department
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