EMS ketamine use on agitated patients on cocaine increases intubation 5.75-fold, study finds
Study examines powerful sedative used for 'excited delirium' and effects
of illicit substances on ensuing hospital intubations

Date:
September 29, 2021
Source:
Florida Atlantic University
Summary:
Patients with excited delirium often are administered ketamine by
EMS before arriving at the hospital. Many of them are intoxicated
or are using illicit substances, which may alter the properties of
ketamine. A study explored if patients who received prehospital
ketamine with concomitant substance intoxication have higher
rates of subsequent intubation in the ER compared to those without
confirmed substance usage.

Among the results, cocaine intoxication had a statistically
significant 5.75-fold increased rate of intubation.



FULL STORY ========================================================================== Patients with excited delirium who are combative, aggressive or agitated
before being transported to the hospital or in an emergency department
setting require immediate treatment for their safety and others. In the
past, physical restraint was the predominant method used to control a
patient during transport. However, due to safety issues, prehospital
ketamine -- a powerful sedative -- is now commonly used to restrain
patients experiencing excited delirium. Emergency medical services
providers typically administer ketamine intramuscularly, which takes
effect in about three to four minutes.


========================================================================== Ketamine is safe and well-tolerated when administered in a controlled environment such as a hospital for procedural sedation, as patients
rarely lose their airway or respiratory drive. Although ketamine use is prevalent, evidence on safety and efficacy is limited and risk factors for respiratory arrest and intubation have not been well studied. Furthermore,
many patients with excited delirium are intoxicated or are using illicit substances and these co- ingestants may alter the properties of the drug.

Researchers from Florida Atlantic University's Schmidt College of Medicine conducted a study to explore whether patients treated with prehospital
ketamine for excited delirium with concomitant substance intoxication
have higher rates of subsequent intubation in the emergency department
compared to those without confirmed substance usage.

Results of the study, published in the journal Prehospital and Disaster Medicine,showed that among 86 patients given prehospital intramuscular
ketamine for excited delirium, those with concomitant cocaine intoxication
had a statistically significant 5.75-fold increased rate of subsequent intubation in the emergency department, which were higher in men than
women. There were no deaths reported.

Patients testing positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates, and synthetic cathinones,
both bath salts and flakka, had similar rates of intubation compared to
those negative for these substances. Baseline characteristics including
age, ketamine dose, and body mass index were similar between those who
did or did not undergo intubation.

"While additional research is needed, it is tempting to speculate
about possible mechanisms whereby prehospital ketamine administered intramuscularly for excited delirium with concomitant cocaine intoxication
may increase subsequent intubation in the emergency department," said
Joshua J. Solano, M.D., first author, an emergency medicine physician,
an assistant professor of emergency medicine and integrated medical
science, and director of quality improvement and patient safety, FAU
Schmidt College of Medicine. "One plausible explanation is that cocaine
may deplete excitatory neurotransmitters and lead to an exaggerated
respiratory depression requiring intubation." Over the course of 28
months, all medical records from two large community hospitals were
searched for all patients age 18 years or older with intramuscular administration of ketamine for excited delirium and identified illicit
and prescription substance co-ingestions.

For the study, trained abstractors collected demographic characteristics, history of present illness, urine drug screens, alcohol levels, and
noted additional sedative administrations. Substance intoxication was determined by urine drug screens and alcohol positivity or negativity,
as well as physician history of present illness. Patients without
toxicological testing or documentation of substance intoxication,
or who may have tested positive due to emergency department sedation,
were excluded from relevant analyses. Subsequent emergency department intubation was the primary pre-specified outcome.

Study co-authors are Lisa M. Clayton, D.O., an emergency medicine
physician, associate professor of integrated medical science and program director of the FAU emergency medicine residency; Daniel J. Parks,
M.D., resident physician, FAU emergency medicine; Shayne E. Polley,
M.D., an FAU medical school graduate and emergency medicine resident
at Christ Emergency Medicine in Oak Lawn, Illinois; Patrick G. Hughes,
D.O, an emergency medicine physician, an assistant program director
of the FAU emergency medicine residency and an associate professor
of integrated medical science; Charles H. Hennekens, M.D., Dr.PH, Sir
Richard Doll professor and senior academic advisor; Richard D. Shih,
M.D., an emergency medicine physician, professor of integrated medical
science, and division director of the FAU emergency medicine residency
program; and senior author Scott M. Alter, M.D., M.B.A., an emergency
medicine physician, an associate professor of emergency medicine, and
associate research director of the FAU emergency medicine residency,
all within the Schmidt College of Medicine.

========================================================================== Story Source: Materials provided by Florida_Atlantic_University. Original written by Gisele Galoustian. Note: Content may be edited for style
and length.


========================================================================== Journal Reference:
1. Joshua J. Solano, Lisa M. Clayton, Daniel J. Parks, Shayne
E. Polley,
Patrick G. Hughes, Charles H. Hennekens, Richard D. Shih, Scott
M. Alter.

Prehospital Ketamine Administration for Excited Delirium with
Illicit Substance Co-Ingestion and Subsequent Intubation in the
Emergency Department. Prehospital and Disaster Medicine, 2021;
1 DOI: 10.1017/ S1049023X21000935 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2021/09/210929092628.htm

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