Agitated patient tearing apart the ED...? Which IM medication do you give?
These
authors from a single ED in Vancouver randomized patients to either ketamine 5mg/kg IM vs. midazolam 5mg plus haloperidol 5mg
IM.
Their primary
outcome was time to adequate sedation as measured on a validated
agitation score.
(They tried
to blind the dose but it’s hard to blind ketamine when we all know what it looks
like. Either way, this was probably only a minor source of potential bias.)
Results?
Enrolment
was cut a bit short at 80 patients due to the start a supposed global
pandemic.
Median time
to adequate sedation was 6 minutes in the ketamine group vs. 15 minutes in those randomized to midazolam/haloperidol.
So, ketamine
is the clear winner?!?!
There are two
major reasons why this conclusion is wrong.
Firstly, they compared a grizzly bear
dose of ketamine to a low dose of midazolam & haloperidol. For
what it is worth, I usually start with midazolam 10mg and droperidol 10mg (unless
there is reason to start lower… elderly, co-morbid, etc.) Droperidol works faster than haloperidol.
Secondly, they asked the wrong research
question. I care less about how quickly someone is sedated and care much more
about how well it works overall. I’m
sure a dose of IM sux would work pretty quick too. Or even a bullet to the head
would have an immediate calming effect (but would be associated
with excess mortality.)
How often
did the ketamine group require re-sedation? How well did the patients wake up? Lots
of adults complain about side effects of ketamine including dysphoria to
emergence phenomenon. But what could go wrong with giving an agitated patient a medication
similar to PCP?
To be fair
to the researchers, it is difficult to objectively measure, “how well did it
work?” It's complicated and there is some subjectivity in this question. Time to sedation is
much easier to measure… but just because we can measure something accurately does
not necessarily mean it is important. (This kind of reminds me of the streetlight effect).
In short
summary, I’m willing to believe a big slug of ketamine will cause someone to
drop quickly. But is this the best thing for the patient? I doubt it.
Covering:
Barbic D,
Andolfatto G, Grunau, et al. Rapid Agitation Control with Ketamine in the ED- A
Blinded, Randomized Controlled Trial. Ann Emerg Med. 2021;78:788-795
[link to full text article]
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