Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-24T05:32:44.188Z Has data issue: false hasContentIssue false
  • English
  • Français

Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System

Published online by Cambridge University Press:  12 August 2016

Thomas R. Scaggs ,
David M. Glass ,
Megan Gleason Hutchcraft  and
William B. Weir
Thomas R. Scaggs*
Affiliation:
Carle Foundation Hospital, Urbana-Champaign, IllinoisUSA
David M. Glass
Affiliation:
University of New Mexico Emergency Medicine Residency, Albuquerque, New MexicoUSA
Megan Gleason Hutchcraft
Affiliation:
The Ohio State University, Department of Ob/Gyn, Columbus, OhioUSA
William B. Weir
Affiliation:
Carle Foundation Hospital, Urbana-Champaign, IllinoisUSA
*
Correspondence: Thomas R. Scaggs, MD 4212 Summer Field Rd. Champaign, Illinois 61822 USA E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Excited delirium syndrome (ExDS) is defined by marked agitation and confusion with sympathomimetic surge and incessant physical struggle, despite futility, which may lead to profound pathophysiologic changes and sudden death. Severe metabolic derangements, including lactic acidosis, rhabdomyolysis, and hyperthermia, occur. The pathophysiology of excited delirium is a subject of ongoing basic science and clinical research. Positive associations with ExDS include male gender, mental health disorders, and substance abuse (especially sympathomimetics).

Excited delirium syndrome patients often exhibit violent, psychotic behavior and have “superhuman” strength which can result in the patient fighting with police and first responders. Continued struggle can cause a patient with ExDS to experience elevated temperature (T) and acidosis which causes enzymes to fail, leading to sudden death from cardiovascular collapse and multi-system organ failure. Therefore, effective early sedation is optimal to stop this fulminant process.

Treatment of ExDS must be focused on rapidly, safely, and effectively sedating the patient and providing intensive, supportive care. Benzodiazepines, like midazolam, may not be ideal to sedate ExDS patients since their onset takes several minutes, and their side effects include loss of airway control and respiratory depression. Injectable antipsychotic medications have a relatively slow onset and may cause prolongation of the QTc interval. Ketamine is the ideal medication to sedate patients with ExDS. Ketamine has a rapid, predictable onset within three to four minutes when given by intramuscular (IM) injection. It does not adversely affect airway control, breathing, heart rate, or blood pressure (BP).

In this retrospective case series, prehospital scenarios in which ExDS patients received ketamine by paramedics for sedation, and their subsequent treatment in the emergency department (ED) and hospital, are described. It is demonstrated that ketamine administered by paramedics in the prehospital setting of a community hospital based Emergency Medical Services (EMS) system is a safe and effective treatment for ExDS.

ScaggsTR, GlassDM, HutchcraftMG, WeirWB. Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System. Prehosp Disaster Med. 2016;31(5):563–569.

Keywords

deliriumEmergency Medical Servicesketaminetherapeutics
Type
Case Reports
Information
Prehospital and Disaster Medicine , Volume 31 , Issue 5 , October 2016 , pp. 563 - 569
Copyright
© World Association for Disaster and Emergency Medicine 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Wetli, CV, Fishbain, DA. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci. 1985;30(3):873-880.CrossRefGoogle ScholarPubMed
2. Ho, JD, Smith, SW, Nystrom, PC, et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehosp Emerg Care. 2013;17(2):274-279.Google Scholar
3. Scheppke, KA, Braghiroli, J, Shalaby, M, Chait, R. Prehospital use of IM ketamine for sedation of violent and agitated patients. West J Emerg Med. 2014;15(7):736-741.Google Scholar
4. 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
5. Nobay, F, Simon, BC, Levitt, MA, Dresden, GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-749.Google ScholarPubMed
6. Spain, D, Crilly, J, Whyte, I, Jenner, L, Carr, V, Baker, A. Safety and effectiveness of high-dose midazolam for severe behavioral disturbance in an emergency department with suspected psychostimulant-affected patients. Emerg Med Australas. 2008;20(2):112-120.CrossRefGoogle Scholar
7. Isbister, GK, Calver, LA, Page, CB, Stokes, B, Bryant, JL, Downes, MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401.e1.Google Scholar
8. Takeuchi, A, Ahern, TL, Henderson, SO. Excited delirium. West J Emerg Med. 2011;12(1):77-83.Google Scholar
9. Haddad, PM, Anderson, IM. Antipsychotic-related QTc prolongation, torsade de pointes, and sudden death. Drugs. 2002;62(11):1649-1671.CrossRefGoogle ScholarPubMed
10. Bozeman, WP, Ali, K, Winslow, JE. Long QT syndrome unmasked in an adult subject presenting with excited delirium. J Emerg Med. 2013;44(2):e207-e210.CrossRefGoogle Scholar
11. Sessler, CN, Gosnell, MS, Grap, MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344.Google Scholar
12. Gerold, KB, Gibbons, ME, Fisette, RE Jr, Alves, D. Review, clinical update, and practice guidelines for excited delirium syndrome. J Spec Oper Med. 2015;15(1):62-69.Google Scholar
13. American College of Emergency Physicians (ACEP). ACEP white paper report on excited delirium syndrome. http://fmhac.net/Assets/Documents/2012/Presentations/ KrelsteinExcitedDelirium.pdf. Published 2009. Accessed January 18, 2016.Google Scholar
14. Vilke, G, Payne-James, J, Karch, S. Excited delirium syndrome (ExDS): redefining an old diagnosis. J Forensic Leg Med. 2012;19(1):7-11.Google Scholar
15. Hick, JL, Smith, SW, Lynch, MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med. 1999;6(1):239-243.CrossRefGoogle ScholarPubMed
16. Vilke, GM, DeBard, ML, Chan, TC, et al. Excited delirium syndrome (ExDS): defining based on a review of the literature. J Emerg Med. 2012;43(5):897-905.Google Scholar
17. Cohen, L, Athaide, V, Wickham, ME, Doyle-Waters, MM, Rose, NG, Hohl, CM. The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Ann Emerg Med. 2015;65(1):43-51.Google Scholar
18. Burnett, AM, Watters, BJ, Barringer, KW, Griffith, KR, Fascone, 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
19 Mash, DC, Duque, L, Pablo, J, et al. Brain biomarkers for identifying excited delirium as a cause of sudden death. Forensic Sci Int. 2009;190(1-3):e13-e19.Google Scholar
20. Schwartz, MD, Trecki, J, Edison, LA, Steck, AR, Arnold, JK, Gerona, RR. A common source outbreak of severe delirium associated with exposure to the novel synthetic cannabinoid ADB-PINACA. J Emerg Med. 2015;48(5):573-580.Google Scholar
21. Hermanns-Clausen, M, Kneisel, S, Szabo, B, Auwärter, V. Acute toxicity due to the confirmed consumption of synthetic cannabinoids: clinical and laboratory findings. Addiction. 2013;108(3):534-544.Google Scholar