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Just reading through abstracts @NAEMSP and felt the need to comment on this one. The researchers looked at patients who received ketamine for excited delirium and compared intubation rates in those who had substance intoxication vs those who did not. 1/
https://www.tandfonline.com/doi/full/10.1080/10903127.2020.1837312
https://www.tandfonline.com/doi/full/10.1080/10903127.2020.1837312
The first point to recognize is that intubating a patient who was extremely combative, enough to need ketamine tranquilization, is not a failure. These are often very sick patients and airway control is quite appropriate. 3/
Intubation is not a negative outcome. Additionally, most of these patients have short ventilator times and do well. 4/
The biggest concern I have, though, is the conclusion. The authors recommend ketamine dose reduction or alternative agents in patients who have substances on board. This is a potentially dangerous recommendation. 5/
The doses of ketamine we use are designed to provide rapid control of a patient who is a hazard to themselves or others. Lower doses (less than 2-3 mg/kg IM or so) may lead to slower or inadequate tranquilization. 6/
Most commonly the alternative agent to ketamine is midazolam. Patients are generally more likely to have airway compromise with midazolam and its effects are less predictable. Droperidol is probably a better alternative than midazolam but it is not as widely available yet. 7/
Ketamine is the most reliable agent for a patient with severe agitation that is an immediate hazard to themselves or others. The idea that we should change our approach out of fear of the patient needing intubation is potentially dangerous. 8/8
(my approach to agitation)
(my approach to agitation)
