EMS Perspectives

August 2020

Jeffrey L. Jarvis, MD, MS, EMT-P, FACEP, FAEMS

As the co-chair (with my colleague Dr. Taylor Ratcliff) of TCEP’s EMS committee, I’m pleased to kick off this introductory EMS Perspectives column. In coming editions, we’ll have TCEP EMS medical directors from across the state offering their insights into the current activities of our EMS agencies. We’ll try to explain the “why” of what we do. We’ll also address some of the controversies in EMS care.

To start us off, I’ll address an issue that has been in the news lately, the use of ketamine sedation for agitated patients. You may have seen coverage in the popular press about police officers ordering EMTs to administer the “killer” drug, ketamine, for people in their custody. Some of these articles strongly suggest that ketamine is responsible for in-custody deaths.

Sadly, this sentiment, while great for its “clickability”, skips right over any subtlety and runs the risk of confusing appropriate and inappropriate uses of a very useful medication. As EM physicians, I think we recognize that, like any medication, ketamine has indications for which it is useful, as well as times where it is contraindicated. This distinction is completely missed in sensational news coverage.

I’d like to go over why many EMS physicians feel ketamine can be an appropriate agent for our field colleagues to use. Before I do that, however, I should be clear about one thing. There is absolutely no role for ketamine to be used or ordered by police officers without medical training and close physician oversight. Fortunately, I don’t think that’s actually happening. The decision to use ketamine, as with any agent, is part of the EMS medical director’s delegated practice. It is a medical decision, not a law enforcement one. In my experience, that’s actually how it is being used.

I think we all know about the role for sub-dissociative dose ketamine for analgesia, and the role for ketamine during RSI. I’ll just focus on the use of ketamine, almost exclusively by the IM route, for violently agitated patients. We’ve all faced these patients in the ED. We’re not talking about anxious or mildly agitated patients. Or those who are simply psychotic. These patients are well treated with benzodiazepines or anti-psychotics.

We’re talking about patients who are altered, hyperdynamic, violent, and unable to be reasoned with. These patients are a danger to themselves and to others. By definition, they can’t be reasoned with (if they could, ketamine isn’t the right drug). Because of the potential for harm to our EMS colleagues, law enforcement officers are often requested for assistance. These patients are medical patients at risk for physiologic decompensation. As physicians, we have an obligation to treat them medically. Ketamine is an ideal agent for this purpose. It is a rapidly acting, effective dissociative agent that, when used in the appropriate doses, can safely sedate these patients. Doing so is the right thing to do for them medically. It decreases the need to physically restrain them in ways that can restrict their ability to effectively ventilate. Because of their hyper-metabolic state, restricting their ability to blow off CO2 can lead to lethal metabolic acidosis. Ketamine allows us to safely and rapidly sedate them and prevent physical restraint that might lead to inhibited ventilation. So, this is the right clinical thing to do for these patients.

So, what is the right dose? Typical dosing is between 4 and 5 mg/kg. Remember, this is IM dosing, NOT the typical 1-2 mg/kg doses we use via IV route for RSI and certainly not the 0.3mg/kg we use by slow infusion for analgesia.

Patients who receive ketamine typically maintain their own airways without intervention. Having said this, some patients may have respiratory depression or laryngospasm. It is vitally important that whoever administers this medication be prepared to closely and continuously monitor these patients until turning them over to ED staff. Medics must be credentialled by their medical directors to manage the airway of these patients.

If an EMS system doesn’t have actively involved EMS physician oversight with continuous quality improvement, they should not be using ketamine. However, if appropriately trained with appropriate physician oversight, ketamine can be a safe and effective medication.

In coming editions, we’ll have a variety of EMS physicians offering their opinions and insights. I hope you’ll stay tuned.