Daniel J. Pallin, MD, MPH reviewing Riddell J et al. Am J Emerg Med 2017 Feb 13.

A small study suggests that ketamine is more effective than alternatives; larger studies are needed to assess safety.

Ketamine has a long history as a veterinary tranquilizer and is familiar to emergency physicians because it is a frequently used, safe, effective agent for procedural sedation and rapid sequence intubation. But can it be used to control behavior in severely agitated patients? In a prior summary of a study on this topic (NEJM JW Emerg Med Mar 2016 and Ann Emerg Med 2016; 67:581), we raised concerns about ketamine's propensity to cause endogenous catecholamine release — what might happen when agitated patients are exposed to even more catecholamines? Now investigators report on a small prospective observational study comparing five regimens for sedation of acutely agitated patients: ketamine (24 patients), lorazepam (33), midazolam (17), haloperidol (14), or haloperidol plus lorazepam or midazolam (10).

Doses and routes of administration varied widely. Effectiveness was superior with ketamine, with a mean time to perceived adequate sedation of 6.6 minutes, versus 18, 15, 13, and 23 minutes with the other regimens, respectively. Adverse events, requirements for redosing, and changes in vital signs were similar among the groups, except that two patients in the ketamine group were intubated, versus one in each of the other groups.

CITATION(S):

Riddell J et al. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med 2017 Feb 13; [e-pub]. 

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