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Ketamine for Pre-Hospital Sedation in Excited Delirium

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2014 PSOW Ketamine Update

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Ketamine for Pre-Hospital Sedation in Excited Delirium

  1. 1. Ketamine for Prehospital Sedation in Excited Delirium Michael D. Curtis, MD, FACEP Charles E. Cady, MD, FACEP
  2. 2. 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
  3. 3. 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
  4. 4. What is the ideal therapeutic approach?  Appropriate supportive therapy  Fluid resuscitation  Reversing metabolic acidosis  Reversing hyperthermia  Have to control the patient first
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Post-ketamine Sedation  Benzodiazepines  Geodon, Zyprexa  Haldol, Droperidol
  9. 9. 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
  10. 10. Adverse reactions  Hypertension and tachycardia  Hypotension and bradycardia  Laryngospasm  Hypersalivation  Nausea and vomiting  Tonic and clonic muscle movements  Roving eyes or nystagmus
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Wisconsin Ketamine Study  Exclusion Criteria  Other uses of Ketamine  Pain management  Asthma  RSI  Other settings  Emergency Department  HEMS  Critical Care Transport  ICU  OR
  18. 18. Wisconsin Ketamine Study  Exclusion Criteria  Other causes  Should we exclude head injury cases with extreme agitation?
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. Wisconsin Ketamine Study  What we need from you  EMS Run Reports (minimum)  ED Records, Discharge Summaries (maximum)  Alternative – Data Collection Form
  25. 25. 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?
  26. 26. Wisconsin Ketamine Study  Our contact information  Michael D. Curtis, MD  Michael.Curtis@ministryhealth.org  715-498-2240  Charles E. Cady, MD  cecady@mcw.edu  262-501-4880
  27. 27. Questions

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