Recently the North Carolina Medical Board approved a ketamine pilot project in North Carolina. Under this pilot, ketamine has been approved for both sedation and pain. The project is very similar to the RSI quality improvement program that has been ongoing in North Carolina for over five years.
As part of the pilot, whenever an EMS provider in an approved EMS system uses ketamine, the system must send in data collection forms to the state so the North Carolina Office of EMS can review and monitor each administration. EMS systems must also collect data from the hospitals on the outcomes of patients receiving ketamine. This will allow the North Carolina Office of EMS and the North Carolina Medical Board to observe how ketamine is utilized.
Ketamine is a drug that has been around since 1966. It is related to PCP and it produces a disassociated state. As with all drugs it has good effects and bad effects. It is the job of medical professionals to use good clinical judgement to decide if the benefits of a certain drug for a particular patient outweigh the risks. One of the good characteristics of ketamine is that it can produce rapid analgesia. It does not normally cause respiratory depression and patients are usually still able to protect their airway. Ketamine can also increase a patient’s blood pressure, which can be a good thing in the right clinical setting. Of course, ketamine is not a perfect drug…
Clinicians need to be knowledgeable about the adverse effects of ketamine so that they can safely use the drug. Ketamine can occasionally cause laryngospasm. This will usually respond to positive pressure from a bag valve mask; although, it is possible that a patient might require intubation. As mentioned above, ketamine can cause an increase in blood pressure since it causes a person’s body to release its own catecholamines (like adrenaline). This can be bad if a patient already has elevated blood pressure or if the patient is experiencing cardiac ischemia. Interestingly, the ketamine molecule can depress cardiac output if the body has already used up most of its internal stores of catecholamines. When pushed quickly via the intravenous route, brief apnea can take place. Lastly, patients who receive ketamine for sedation will occasionally wake up in a state of extreme agitation and confusion. This is known as an emergence reaction, and can often be resolved through gentle coaching. Small doses of benzodiazepines can also assist with these type reactions.
In the state protocols approved for the pilot project, ketamine is listed as one of many options that providers may use. The two state protocols where ketamine has been approved are the pain protocol and the behavioral protocol. Within these protocols providers are not required to use ketamine, and providers should only use ketamine in the correct clinical situation. The decision to use ketamine for either pain control or sedation is a medical decision. I will quickly review the two pilot protocols, pain and behavioral, which include ketamine.
The pain protocol still utilizes several different medications to address a patient’s pain. As stated above providers should only use ketamine if they feel it is appropriate given the clinical situation. Medications also available within the pain protocol include ibuprofen, acetaminophen, aspirin, ketorolac, nitrous oxide, and narcotics or opiates, to include morphine as well fentanyl. Ketamine can be effective at treating pain and it addresses pain by a different mechanism than the other medications. When ketamine is given for pain the dose is 0.2 mg/kg. It should be given in 50-250 mL of normal saline. The infusion should go in over 10 minutes. The infusion is given over 10 minutes to lessen the chance of the patient having hallucinations or other bad experiences; although, even when given over 10 minutes such an adverse reaction can still occur. A 10 minute infusion time may also lessen any positive or negative effects on blood pressure. Patients receiving ketamine for pain should at a minimum have continuous capnography placed, in addition to monitoring all standard vital signs.
The second protocol, which includes ketamine, is the behavioral protocol. The decision to use Ketamine is a medical decision. In other words the medical providers are the ones at the scene who decide whether to use ketamine. As with the pain protocol, the behavioral protocol offers multiple medications which can be used. These include midazolam, ketamine, and haloperidol. The specific syndrome within the protocol where ketamine is indicated is Excited Delirium. Excited Delirium is not very common so it will likely not be seen very often in any one EMS system. The dosing for ketamine in the patient with excited delirium is 400 mg IM. The excited delirium patient may often have a medical or toxicological cause for their condition. For this reason providers should assume that any patient with excited delirium has a dangerous medical or toxicological condition. A full assessment should be done and the patient must be intensively monitored. Providers must also be ready to initiate any lifesaving interventions as indicated. All patients who receive ketamine at a minimum should have continuous capnography applied. Patients who receive ketamine for excited delirium require close observation, including cardiac monitoring, BP, and continuous capnography.
In summary ketamine is an important drug in our toolbox. Like all medications it is not a perfect drug. It has benefits as well as side effects. Before providers use ketamine they should receive appropriate training from their agency and medical director. Ketamine should only be used in the appropriate clinical situation. Many times there will be other drugs which might be more helpful for a given scenario. Any system in North Carolina has been able to use ketamine for RSI. Now counties which are participating in the state pilot project may use ketamine within the pain and behavioral protocols. Participation in the pilot project does not require a provider to use ketamine. It should only be used in the correct clinical situation and that decision should be made by the highly trained medical providers caring for that patient.