Ketamine for the difficult-to-sedate ER patient
For the small segment of the emergency population whose acute behavioral disturbance does not respond to traditional sedation, ketamine appears to be effective and safe, according to an Australian study published online last Thursday in Annals of Emergency Medicine ("Ketamine for Difficult to Sedate Severe Acute Behavioral Disturbance in the Emergency Department").
"Difficult to sedate patients with behavioral disturbances are highly problematic for emergency department staff," said Geoff Isbister, MD, of the Clinical Toxicology Research Group at the University of Newcastle in Newcastle, Australia. "Although such patients are uncommon, they cause significant disruption and danger to emergency department staff and consume time and resources required for other patients. Ketamine is a reasonable third-line agent to use on these patients once other sedation options have been exhausted."
Of 49 emergency patients who were treated with ketamine to achieve sedation for acute behavioral disturbances, only 10 percent either did not achieve sedation within 2 hours or required additional sedation within 1 hour. Patients were treated with ketamine only after sedation was attempted with droperidol in the majority of cases. Average time to sedation after ketamine was 20 minutes.
Police were involved with 20 of the 49 subjects, of whom 57 percent were male.
"Most agitated and aggressive patients in the emergency department will either respond to verbal de-escalation or oral sedation, or be rapidly sedated with droperidol" said Dr. Isbister. "For the small number who don't, we have ketamine."