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Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine

Published online by Cambridge University Press:  19 September 2016

Travis D. Olives Open the ORCID record for Travis D. Olives [Opens in a new window] ,
Paul C. Nystrom ,
Jon B. Cole ,
Kenneth W. Dodd  and
Jeffrey D. Ho
Travis D. Olives*
Affiliation:
Minnesota Poison Control System, Minneapolis, MinnesotaUSA Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MinnesotaUSA
Paul C. Nystrom
Affiliation:
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MinnesotaUSA
Jon B. Cole
Affiliation:
Minnesota Poison Control System, Minneapolis, MinnesotaUSA Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MinnesotaUSA
Kenneth W. Dodd
Affiliation:
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MinnesotaUSA
Jeffrey D. Ho
Affiliation:
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MinnesotaUSA
*
Correspondence: Travis D. Olives, MD Minnesota Poison Control System 701 Park Avenue Mail code: RLL Minneapolis, Minnesota USA 55415 E-mail: [email protected]
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Abstract

Background

Profound agitation in the prehospital setting confers substantial risk to patients and providers. Optimal chemical sedation in this setting remains unclear.

Objective

The goal of this study was to describe intubation rates among profoundly agitated patients treated with prehospital ketamine and to characterize clinically significant outcomes of a prehospital ketamine protocol.

Methods

This was a retrospective cohort study of all patients who received prehospital ketamine, per a predefined protocol, for control of profound agitation and who subsequently were transported to an urban Level 1 trauma center from May 1, 2010 through August 31, 2013. Identified records were reviewed for basic ambulance run information, subject characteristics, ketamine dosing, and rate of intubation. Emergency Medical Services (EMS) ambulance run data were matched to hospital-based electronic medical records. Clinically significant outcomes are characterized, including unadjusted and adjusted rates of intubation.

Results

Overall, ketamine was administered 227 times in the prehospital setting with 135 cases meeting study criteria of use of ketamine for treatment of agitation. Endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. Male gender and late night arrival were associated with intubation in univariate analyses (χ2=12.02; P=.001 and χ2=5.34; P=.021, respectively). Neither ketamine dose, co-administration of additional sedating medications, nor evidence of ethanol (ETOH) or sympathomimetic ingestion was associated with intubation. The association between intubation and both male gender and late night emergency department (ED) arrival persisted in multivariate analysis. Neither higher dose (>5mg/kg) ketamine nor co-administration of midazolam or haloperidol was associated with intubation in logistic regression modeling of the 120 subjects with weights recorded. Two deaths were observed. Post-hoc analysis of intubation rates suggested a high degree of provider-dependent variability.

Conclusions

Prehospital ketamine is associated with a high rate of endotracheal intubation in profoundly agitated patients; however, ketamine dosing is not associated with intubation rate when adjusted for potential confounders. It is likely that factors not included in this analysis, including both provider comfort with post-ketamine patients and anticipated clinical course, play a role in the decision to intubate patients who receive prehospital ketamine.

OlivesTD, NystromPC, ColeJB, DoddKW, HoJD. Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine. Prehosp Disaster Med. 2016;31(6):593–602.

Keywords

agitationexcited deliriumintubationprehospital ketaminesedation
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 31 , Issue 6 , December 2016 , pp. 593 - 602
Copyright
© World Association for Disaster and Emergency Medicine 2016 

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References

1. Ahern, TL, Herring, AA, Stone, MB, Frazee, BW. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J Emerg Med. 2013;31(5):847-851.Google Scholar
2. Adelgais, KM, Brown, K. Pediatric prehospital pain management: impact of advocacy and research. Clin Pediatr Emerg Med. 2014;15(1):49-58.Google Scholar
3. Green, SM, Rothrock, SG, Harris, T, Hopkins, GA, Garrett, W, Sherwin, T. Intravenous ketamine for pediatric sedation in the emergency department: safety profile with 156 cases. Acad Emerg Med. 1998;5(10):971-976.Google Scholar
4. Green, SM, Denmark, TK, Cline, J, Roghair, C, Abd Allah, S, Rothrock, SG. Ketamine sedation for pediatric critical care procedures. Pediatr Emerg Care. 2001;17(4):244-248.Google Scholar
5. McCarty, EC, Mencio, GA, Walker, LA, Green, NE. Ketamine sedation for the reduction of children’s fractures in the emergency department. J None Joint Surg Am. 2000;82–A(7):912-918.Google Scholar
6. Roback, MG, Wathen, JE, Bajaj, L, Bothner, JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med. 2005;12(6):508-513.Google Scholar
7. Jennings, PA, Cameron, P, Bernard, S, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012;59(6):497-503.Google Scholar
8. Jennings, PA, Cameron, P, Bernard, S. Ketamine as an analgesic in the pre-hospital setting: a systematic review. Acta Anaesthesiol Scand. 2011;55(6):638-643.Google Scholar
9. Tran, KP, Nguyen, Q, Truong, XN, et al. A comparison of ketamine and morphine analgesia in prehospital trauma care: a cluster randomized clinical trial in rural Quang Tri Province, Vietnam. Prehosp Emerg Care. 2014;18(2):257-264.Google Scholar
10. Wiel, E, Zitouni, D, Assez, N, et al. Continuous infusion of ketamine for out-of-hospital isolated orthopedic injuries secondary to trauma: a randomized controlled trial. Prehosp Emerg Care. 2015;19(1):10-16.Google Scholar
11. Paix, BR, Capps, R, Neumeister, G, Semple, T. Anesthesia in a disaster zone: a report on the experience of an Australian medical team in Banda Aceh following the Boxing Day Tsunami. Anaesth Intensive Care. 2005;33(5):629-634.Google Scholar
12. Mellor, AJ. Anesthesia in austere environments. J R Army Med Corps. 2005;151(4):272-276.Google Scholar
13. Maher, PJ, Walsh, M, Burns, T, Strote, J. Prehospital resuscitation of a man with excited delirium and cardiopulmonary arrest. CJEM. 2014;16(1):80-83.CrossRefGoogle Scholar
14. Southall, P, Grant, J, Fowler, D, Scott, S. Police custody deaths in Maryland, USA: an examination of 45 cases. J Forensic Leg Medicine. 2008;15(4):227-230.Google Scholar
15. Bunai, Y, Akaza, K, Jiang, WX, Nagai, A. Fatal hyperthermia associated with excited delirium during arrest. Leg Med (Tokyo). 2008;10(6):306-309.CrossRefGoogle ScholarPubMed
16. Hick, JL, Smith, SW, Lynch, MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med. 1999;6(3):239-243.Google Scholar
17. O’Halloran, RL, Lewman, LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol. 1993;14(4):289-295.CrossRefGoogle ScholarPubMed
18. Strote, J, Walsh, M, Auerbach, D, Burns, T, Maher, P. Medical conditions and restraint in patients experiencing excited delirium. Am J Emerg Med. 2014;32(9):1093-1096.Google Scholar
19. Chan, TC, Neuman, T, Clausen, J, Eisele, J, Vilke, GM. Weight force during prone restraint and respiratory function. Am J Forensic Med Pathol. 2004;25(3):185-189.Google Scholar
20. Ho, JD, Dawes, DM, Moore, JC, Caroon, LV, Miner, JR. Effect of position and weight force on inferior vena cava diameter – implications for arrest-related death. Forensic Sci Int. 2011;212(1-3):256-259.Google Scholar
21. Chan, TC, Vilke, GM, Neuman, T, Clausen, JL. Restraint position and positional asphyxia. Ann Emerg Med. 1997;30(5):578-586.CrossRefGoogle ScholarPubMed
22. Reay, DT, Howard, JT, Fligner, CL, Ward, RJ. Effects of positional restraint on oxygen saturation and heart rate following exercise. Am J Forensic Med Pathol. 1988;9(1):16-18.Google Scholar
23. Chan, TC, Vilke, GM, Neuman, T. Reexamination of custody restraint position and positional asphyxia. Am J Forensic Med Pathol. 1998;19(2):201-205.CrossRefGoogle ScholarPubMed
24. Isenberg, DL, Jacobs, D. Prehospital Agitation and Sedation Trial (PhAST): a randomized control trial of intramuscular haloperidol versus intramuscular midazolam for the sedation of the agitated or violent patient in the prehospital environment. Prehosp Disaster Med. 2015;30(5):491-495.Google Scholar
25. Burnett, AM, Salzman, JG, Griffith, KR, Kroeger, B, Frascone, RJ. The emergency department experience with prehospital ketamine: a case series of 13 patients. Prehosp Emerg Care. 2012;16(4):553-559.Google Scholar
26. 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 Scholar
27. Hick, JL, Ho, JD. Ketamine chemical restraint to facilitate rescue of a combative “jumper.” Prehosp Emerg Care. 2005;9(1):85-89.Google Scholar
28. Ho, JD, Smith, SW, Nystrom, PC, et al. Successful management of excited delirium with prehospital ketamine: two case examples. Prehosp Emerg Care. 2013;17(2):274-279.Google Scholar
29. Pritchard, A, LeCong, M. Ketamine sedation during air medical retrieval of an agitated patient. Air Med J. 2014;33(2):76-77.Google Scholar
30. Svenson, JE, Abernathy, MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007;25(8):977-980.Google Scholar
31. Iwanicki, JL, Barrett, W, Saghafi, O, et al. Prehospital ketamine for excited delirium in the setting of acute drug intoxication. Clin Toxicol. 52(7):685 (Abstract #9).Google Scholar
32. Cole, JB, Nystrom, PC, Orozco, BS, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol. 53(7):642 (Abstract #7).Google Scholar
33. Hennepin County EMS System. Advanced Life Support Protocols. Emergency Medical Services Planning and Regulation. Web site. http://www.hennepin.us/business/work-with-henn-co/ems-planning-reg. Accessed September 17, 2014.Google Scholar
34. Olives, TD, Nystrom, PN, Ho, JD, Cole, JB. A patient administered prehospital ketamine on 20 separate occasions. Clin Toxicol. 2013;51:675.Google Scholar
35. NMS Labs. Sample Report Amphetamines Panel (8600B). Willow Grove, Pennsylvania USA: NMS Labs; 2014. Robert A. Middleberg, Laboratory Director.Google Scholar
36. Burnett, AM, Watters, BJ, Barringer, KW, Griffith, KR, Frascone, RJ. Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehosp Emerg Care. 2012;16(3):412-414.Google Scholar
37. Boyer, EW, Shannon, M. The serotonin syndrome. NEJM. 2005;352(11):1112-1120.Google Scholar
38. 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.Google Scholar