Patients suffering from excited delirium, who are aggressive, combative, or distressed prior to being transferred to the hospital or emergency department setting should seek immediate treatment to ensure their safety. In the past physical restraint was the most common method of controlling patients during transportation. However due to safety concerns that prehospital ketamine, a powerful sedative – is now commonly used to restrain patients experiencing excited delirium. The effects of ketamine are typically felt intramuscularly by emergency medical care providers. This takes about three to four minutes.
Because patients aren’t likely to lose their respiratory drive or airway, ketamine is well-tolerated and safe when administered in a controlled environment like in a hospital. The use of ketamine is widespread however there isn’t any evidence of its safety or efficacy. Also the risk factors that could lead to respiratory arrest and intubation are not well-studied. Many patients experiencing excited delirium might be drunk or using illicit substances, which can alter the effects of the drug.
Florida Atlantic University’s Schmidt College of Medicine performed a study to determine whether patients who received prehospital ketamine to treat delusions and concurrent use of drugs had higher rates of intubation within the emergency department than those who had not confirmed use of a substance.
Results of the study, published in the journal Prehospital and Disaster Medicine,showed that among 86 patients who received prehospital intramuscular ketamine for the treatment of excited delirium, those with concurrent cocaine intoxication had an statistically significant 5.75-fold greater chance of intubation in the emergency department. These rates were higher for men than women. There were no deaths reported.
Patients who tested positive for amphetamines and alcohol barbiturates and benzodiazepines marijuana, opiates, ecstasy, and synthetic cathinones, both flakka and bath salts were similarly intubated compared to those who tested negative for these substances. Baseline characteristics including age, ketamine dose, and body mass index were similar to those who underwent or did not undergo intubation.
Although more research is needed, it is tempting to speculate on possible mechanisms the use of intramuscular ketamine in prehospital settings to induce delirium and cocaine intoxication might increase subsequent intubation at an emergency department. One possible reason is that cocaine can deplete excitatory neurotransmitters and lead to an increased respiratory depression requiring intubation.”
Joshua J. Solano, M.D., first author, emergency medicine physician, assistant professor of emergency medicine and integrated medical sciences, and director of quality improvement and patient safety, FAU Schmidt College of Medicine
Over the course of 28 month, all medical records of two large community hospitals were scanned to find all patients 18 or over who had received intramuscular ketamine to treat their the state of excitement.
The study was conducted by experienced abstractors who took information on demographics, history of illness, urine drug screens, alcohol level, and any additional sedatives administered. Substance intoxication was determined by urine drug screens and alcohol positivity or negative, as well as physician information regarding the current illness. Patients who did not undergo toxicological testing or documentation of alcohol intoxication, or who may have been tested positive because of emergency department sedation, were excluded from relevant studies. Intubation in the emergency room was the primary outcome.
et. et. (2021). Prehospital Ketamine Administration for Excited delusions caused by Illicit Substance Co-Ingestion and Intubation Subsequently at the Emergency Department. Prehospital and Disaster Medicine. doi.org/10.1017/S1049023X21000935.
Content Source: https://www.news-medical.net/news/20210929/Ketamine-use-on-patients-with-excited-delirium-and-cocaine-intoxication-increases-intubation-rate.aspx