PSOW 2012 - ExDS and Ketamine
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Ketamine for the Ketamine for the Control of the Control of the Agitated and Agitated and Combative: Combative: The Wisconsin The Wisconsin Experience Experience Michael D. Curtis, MD, Michael D. Curtis, MD, FACEP FACEP EMS Medical Director EMS Medical Director Ministry Health Care Ministry Health Care Stevens Point, Wisconsin Stevens Point, Wisconsin
Transcript of PSOW 2012 - ExDS and Ketamine
Ketamine for the Control of Ketamine for the Control of the Agitated and Combative:the Agitated and Combative:The Wisconsin ExperienceThe Wisconsin Experience
Michael D. Curtis, MD, FACEPMichael D. Curtis, MD, FACEPEMS Medical DirectorEMS Medical DirectorMinistry Health CareMinistry Health Care
Stevens Point, WisconsinStevens Point, Wisconsin
ObjectivesObjectives
Describe the Excited Delirium Describe the Excited Delirium Syndrome (ExDS) Treatment TriadSyndrome (ExDS) Treatment Triad
Describe the characteristic of the Describe the characteristic of the ideal drug for controlling agitationideal drug for controlling agitation
State why Ketamine may represent State why Ketamine may represent the ideal drug for this purposethe ideal drug for this purpose
Identify lessons learned regarding Identify lessons learned regarding Ketamine therapy in the setting of Ketamine therapy in the setting of ExDSExDS
Excited Delirium SyndromeExcited Delirium Syndrome
Agitation
Acidosis Hyperthermia
Source: Chief John Gardner (MDCFR); IPICD Conference – Nov. 2007 Las Vegas
Treatment Triad
“Treat the Triad!”
Therapeutic ConsiderationsTherapeutic Considerations
The first goal of therapy is to gain The first goal of therapy is to gain control of the behaviorcontrol of the behavior
The second goal of therapy is to The second goal of therapy is to stabilize the underlying physiological stabilize the underlying physiological processesprocesses
Drugs Used for SedationDrugs Used for Sedation
BenzodiazepinesBenzodiazepines• Valium, Versed, AtivanValium, Versed, Ativan
AntipsychoticsAntipsychotics• Haldol, DroperidolHaldol, Droperidol
Atypical antipsychoticsAtypical antipsychotics• Geodon, ZyprexaGeodon, Zyprexa
Dissociative anesthetic agentDissociative anesthetic agent• KetamineKetamine
Sedation for ExDSSedation for ExDS
Characteristics of an ideal drugCharacteristics of an ideal drug• Rapidly effective in a single doseRapidly effective in a single dose• Minimal adverse effectsMinimal adverse effects
CardiovascularCardiovascularRespiratoryRespiratoryNeurologicalNeurologicalHyperthermiaHyperthermiaDrug interactionsDrug interactions
Ketamine for ExDSKetamine for ExDS
Very rapid onset of actionVery rapid onset of action• (<5 minutes)(<5 minutes)
Highly effective in a single doseHighly effective in a single dose Favorable safety profile in healthy Favorable safety profile in healthy
patientspatients• Supports heart rate and blood pressureSupports heart rate and blood pressure• Preserves respiratory drivePreserves respiratory drive• Some neurological concernsSome neurological concerns
Limited data for this indicationLimited data for this indication
The Wisconsin ExperienceThe Wisconsin Experience
Portage CountyPortage County BeloitBeloit BarabooBaraboo Lake Country Lake Country
(Delafield)(Delafield) Dane CountyDane County Eau ClaireEau Claire Chippewa FallsChippewa Falls Others?Others?
Prehospital Goals of TherapyPrehospital Goals of Therapy
Quickly and effectively gain Quickly and effectively gain compliance with a single dosecompliance with a single dose• 5 mg/kg IM5 mg/kg IM• 2 mg/kg IN ???2 mg/kg IN ???• 1-2 mg/kg IV1-2 mg/kg IV
Prevent violent struggle with police Prevent violent struggle with police and ongoing struggle against and ongoing struggle against restraintsrestraints
Ensure EMS crew safetyEnsure EMS crew safety
Prehospital Goals of TherapyPrehospital Goals of Therapy
Gain IV access for fluid and Gain IV access for fluid and medication administrationmedication administration
Initiate supportive therapiesInitiate supportive therapies Transport to the emergency Transport to the emergency
department for definitive evaluation department for definitive evaluation and managementand management
Monitor carefullyMonitor carefully
Profile of Ketamine CasesProfile of Ketamine CasesTime FrameTime Frame April 2009 through April 2009 through
August 2012August 2012
Number of CasesNumber of Cases 3636
BeloitBeloit
Portage CountyPortage County
Lake CountryLake Country
Chippewa FallsChippewa Falls
20 (Barb & Rick)20 (Barb & Rick)
10 (Michael)10 (Michael)
5 (Lynn and Paul)5 (Lynn and Paul)
1 (Justus and Eric)1 (Justus and Eric)
Profile of Ketamine CasesProfile of Ketamine CasesAgeAge
(*Outliers Removed)(*Outliers Removed)Average: 33.0 (13-81)Average: 33.0 (13-81)
Average: 32.3* (17-60)Average: 32.3* (17-60)
SexSex Male: 63%Male: 63%
EthnicityEthnicity White: 56%White: 56%
Black: 25%Black: 25%
Hispanic: 5%Hispanic: 5%
Unknown: 14%Unknown: 14%
Time of Day DifferencesTime of Day Differences
Frequency of Cases by Time of Day
0%
10%
20%
30%
40%
50%
1
Time of Day
Rel
ativ
e F
req
uen
cy N
=
36
03--09
09--15
15--21
21--03
Seasonal DifferencesSeasonal Differences
Seasonal Variation in Cases
0%5%
10%15%20%25%30%35%40%
1
Seasons
Rel
ativ
e F
req
uen
cy N
=36
Winter
Spring
Summer
Fall
Performance DataPerformance DataWere the indications met?Were the indications met? 94%94%
Was the correct dosage Was the correct dosage given?given?
86%86%
Was the desired control Was the desired control achieved in <5 minutes?achieved in <5 minutes?
81%81%
Were there any Were there any complications due to complications due to Ketamine?Ketamine?
(4) 11%(4) 11%
Were there any other Were there any other unusual occurrences?unusual occurrences?
(3) 8%(3) 8%
Not IndicatedNot Indicated
Post-op delirium casePost-op delirium case Postictal psychosis or deliriumPostictal psychosis or delirium Hypoglycemic delirium??Hypoglycemic delirium??
When you are up to your ass in alligators, sometimes it’s difficult to remember that
your initial objective was to drain the swamp!
Under DosingUnder Dosing
The DOC recommended a lower doseThe DOC recommended a lower dose• Why did you ask?Why did you ask?
The MEDIC underestimated the The MEDIC underestimated the weight.weight.• ““No dear, that dress doesn’t make you No dear, that dress doesn’t make you
look fat!”look fat!” The PATIENT had mostly calmed The PATIENT had mostly calmed
down alreadydown already• The fluctuating course of deliriumThe fluctuating course of delirium
IneffectiveIneffective
Under dosingUnder dosing How extreme can agitation become?How extreme can agitation become?
• We have stories to tell…We have stories to tell…
Adverse EffectsAdverse Effects
““The usual suspects”The usual suspects”• Laryngospasm, drooling, nausea and Laryngospasm, drooling, nausea and
vomitingvomiting WorrisomeWorrisome
• Possible drug interactionsPossible drug interactions E.g., EtOH, Narcs, BZDs, Meth, Coc, psych E.g., EtOH, Narcs, BZDs, Meth, Coc, psych
meds, etc.meds, etc.
• IntubationsIntubations Bellwether of doom for ketamine?Bellwether of doom for ketamine? How many would have been tubed anyway?How many would have been tubed anyway?
Unusual OccurrencesUnusual Occurrences
Elderly man with sun downingElderly man with sun downing Postictal psychosis or delirium.Postictal psychosis or delirium.
DiscussionDiscussion
Ketamine is indicated for controlling Ketamine is indicated for controlling agitated, combative and violent agitated, combative and violent behavior of persons in police custodybehavior of persons in police custody
The goal is a full dissociative stateThe goal is a full dissociative state The full dissociative dose is 5 mg/kg The full dissociative dose is 5 mg/kg
IMIM Two cases of apparent failure were Two cases of apparent failure were
reportedreported
DiscussionDiscussion
Paramedics can correctly dose Paramedics can correctly dose ketamine by protocolketamine by protocol
Medical control variability may Medical control variability may account for some response variabilityaccount for some response variability
Well known adverse effects of Well known adverse effects of ketamine are observed in low ketamine are observed in low frequencyfrequency
DiscussionDiscussion
Several patients were intubated, Several patients were intubated, which raises several questions…which raises several questions…• Does respiratory depression occur when Does respiratory depression occur when
ketamine is combined with alcohol, ketamine is combined with alcohol, narcotics, or other CNS depressants?narcotics, or other CNS depressants?
• Can intubation be avoided with careful Can intubation be avoided with careful monitoring and supportive care?monitoring and supportive care?
What do you think?What do you think?
