From the land of “we still have droperidol”, this case series details the use of ketamine as “rescue” treatment for “agitated delirium”. In lay terms, the situation they’re describing is the utterly bonkers patient being physically restrained by law enforcement for whom nothing else has worked.
In this case series, which represented only 49 of 1,296 patients with acute agitation, intramuscular ketamine was used as second- or third-line therapy behind droperidol and benzodiazepines. Target dosing was 4-6 mg/kg, similar to procedural sedation. Of the 49 requiring rescue ketamine, 44 were effectively sedated within 120 minutes – with a median time to sedation of 20 minutes. The patients who were not adequately sedated with their initial dose of ketamine almost all received deliberate underdosing out of concern for potential respiratory impairment.
Three patients suffered adverse effects – two with vomiting, and one with desaturation 40 minutes after ketamine. As with any observational series without a control, particularly a small one, little can be conclusively stated regarding the safety. However, it is reasonable to consider any potential harms from such large doses of ketamine in the context of the harms of alternative sedating agents or injuries from continued agitation.
It may even be worth trying on the big green guy.
“Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department”
They use alpha-2 agonists for sedation all the time in veterinary medicine – but it doesn’t look like it has a role here in the Emergency Department.
This is a small case-series out of Australia in which they gave dexmedetomidine (Precedex) to the acutely behaviorally challenged – a high-risk population in the Emergency Department, both for the patient and for staff. Patients became eligible for dexmedetomidine if they had acute behavioral disturbance requiring physical and chemical restraint. In this hospital, their protocol was to use droperidol 10mg IV for chemical sedation, then a second 10mg dose, and then they became eligible for second-line agents.
Their study population is thirteen patient enrollment over 21 months constituting a heterogenous mix of toxicologic and psychiatric agitation. Five of the thirteen patients received an IV loading dose only, and the remaining eight received loading dose and infusion. Of the five who received the loading dose, 2 had effective sedation without adverse effects – and the other 3 were not sedated and one became hypotensive. Of the other eight, three had effective sedation, one of which developed hypotension and atrial fibrillation. The other five had only transient or no sedation, four became hypotensive, and two were intubated for persistent agitation.
So, in all, five of the thirteen had adequate sedation using dexmedetomidine as rescue after initial attempts at chemical sedation – but seven had adverse effects. The authors then conclude that, while it provides an additional, reasonable alternative for sedation, monitoring and managing the adverse effects would be too resource intensive.
Seems reasonable enough.
“Dexmedetomidine in the emergency department: assessing safety and effectiveness in difficult-to-sedate acute behavioural disturbance”
Anyone working in the Emergency Department knows that homelessness and psychiatric disorders go hand-in-hand – and that also goes psychiatric disorders and substance abuse. This study confirms what we already know about the prevalence of these issues in the homeless population.
The most interesting number I read out of it was that the life expectancy of a homeless male aged 15-24 years was 38.7, and 47.4 for similarly aged homeless females – compared to life expectancies of 60.3 and 64.8 in their general population. It makes me wonder how much of that life expectancy difference is just the homelessness, or whether it’s the psychiatric and substance abuse disorders – I would probably say most of that difference is made up with the substance abuse.
“Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study.”
Not as helpful an article as I hoped when I pulled it to peruse. Part of the issue is the surveys are administered to psychiatry and emergency department residents regarding their evaluation of the patient, so you’re almost certain to have a lot more variability – not just in assessment, but in level of understanding of language and the process of acute psychiatric assessment.
Where I’m not surprised we have a low kappa with our psych colleagues are areas like mood disorders – as emergency physicians are looking more at threat to themselves, threat to others, acute psychosis, and other factors affecting their global level of function to determine whether they are safe for discharge. What’s interesting are the 2×2 tables regarding things like suicidality, where psychiatry is eliciting suicidality in a significant number of individuals where that was not reported by the emergency physician. Out in community practice where psychiatry is not always readily available, the discharge of psychiatry patients is a high-risk endeavor – and I would have expected the emergency physician to be more attuned to suicide risk and document a lot more concern for suicidality that was deemed not an issue for the consulting team.
Mostly just an article to read out of passing curiosity that won’t impact your practice.