title: Prehospital use of i.m. ketamine for sedation of violent and agitated patients.
abstract: BACKGROUND
  Violent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear. The objective is to demonstrate that ketamine, given as a single intramuscular injection for violent and agitated patients, including those with suspected excited delirium syndrome (ExDS), is both safe and effective during the prehospital phase of care, and allows for the rapid sedation and control of this difficult patient population.
  
  
  METHODS
  We reviewed paramedic run sheets from five different catchment areas in suburban Florida communities. We identified 52 patients as having been given intramuscular ketamine 4 mg/kg i.m., following a specific protocol devised by the EMS medical director of these jurisdictions, to treat agitated and violent patients, including a subset of which would be expected to suffer from ExDS. Twenty-six of 52 patients were also given parenteral midazolam after medical control was obtained to prevent emergence reactions associated with ketamine.
  
  
  RESULTS
  Review of records demonstrated that almost all patients (50/52) were rapidly sedated and in all but three patients no negative side effects were noted during the prehospital care. All patients were subsequently transported to the hospital before ketamine effects wore off.
  
  
  CONCLUSIONS
  Ketamine may be safely and effectively used by trained paramedics following a specific protocol. The drug provides excellent efficacy and few clinically significant side effects in the prehospital phase of care, making it an attractive choice in those situations requiring rapid and safe sedation especially without intravenous access.
authors.affiliation: University of Miami Miller School of Medicine Palm Beach Regional Campus, JFK Medical Center, Department of Emergency Medicine, Atlantis, Florida.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Scheppke
authors.affiliation: University of Miami, Miller School of Medicine, Miami, Florida.
authors.forename: Joao
authors.initials: J
authors.lastname: Braghiroli
authors.affiliation: Metrohealth Medical Center Case-Western Reserve University, Department of Hospital Medicine, Cleveland, Ohio.
authors.forename: Mostafa
authors.initials: M
authors.lastname: Shalaby
authors.affiliation: University of Miami Miller School of Medicine Palm Beach Regional Campus, JFK Medical Center, Department of Cardiology, Atlantis, Florida.
authors.forename: Robert
authors.initials: R
authors.lastname: Chait
mesh_terms: D000778:Anesthetics, Dissociative / Q000008:administration & dosage*; D003617:Dangerous Behavior; D003693:Delirium / Q000150:complications / Q000188:drug therapy*; D004632:Emergency Medical Services / Q000379:methods*; D004634:Emergency Medical Technicians; D005431:Florida; D006801:Humans; D007273:Injections, Intramuscular; D007649:Ketamine / Q000008:administration & dosage*; D017410:Practice Guidelines as Topic; D011595:Psychomotor Agitation / Q000188:drug therapy* / Q000209:etiology; D012189:Retrospective Studies; D017751:Safety Management; D014754:Violence / Q000517:prevention & control*
chemical_list: D000778:Anesthetics, Dissociative; D007649:Ketamine