PAIN MANAGEMENT AND SEDATION/EDITORIAL

Lets Take Em Down With a Ketamine Blow Dart

Steven M. Green, MD*; Gary Andolfatto, MD
*Corresponding Author. E-mail: [email protected].
0196-0644/$-see front matter
Copyright 2016 by the American College of Emergency Physicians.
http://dx.doi.org/10.1016/j.annemergmed.2016.01.002

SEE RELATED ARTICLE, P.

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[Ann Emerg Med. 2016;-:1-3.]

Agitated, unpredictable, and violent patients. We all
see them. Fueled by some toxic combination of druginduced delirium, inebriated anger, paranoid delusions, or
pernicious personality, these erratic and dangerous patients
present an imminent threat to emergency department (ED)
staff and to themselves. They are legendary in their
imperviousness to pain and acts of superhuman strength.
Typically, these patients are grappled with by police
or hospital security staff and administered intramuscular
antipsychotics (with or without benzodiazepines). We then
stand back and count the agonizing minutes until it might
become safe to further assess and treat them. In dire
situations, we may be forced to give intramuscular
succinylcholine and crash intubate to achieve situational
control. In these scenarios, there are substantial risks to
staff of injury and body uid exposure, and patients are
at risk of sudden death during the struggle.1
In this issue, Isbister et al2 describe 49 adults with
acute behavioral disturbance who were sedated with
intramuscular ketamine. Yes, ketamine. During this studys
peer review, an experienced reviewer reacted: This is just
crazy.. [T]he last thing we need is for a bunch of residents
or docs to whack psych patients with ketamine in order
to sedate them.
But is this crazy? There is ample precedent for taking
down beasts in the wild with ketamine. Remember those
nature shows in which biologists shoot tranquilizer darts into
rhinos or lions or polar bears? It should be no surprise that
ketamine has been and continues to be the most common
ingredient in such animal blow darts.3 So why not treat
peoplewhen the situation requires itlike wild beasts? But
with intramuscular ketamine injection rather than an actual
blow dart rie. We all know from our procedural sedation
practice that ketamine has rapid onset after intramuscular
injection (usually 2 to 5 minutes) and that immobilization
and cardiorespiratory stability are key features of the resulting
trancelike dissociative state.4 Isnt this the ideal formula for
taking down a wild beast of a patient?
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In the current study, Isbister et al2 administered

ketamine in full procedural sedation doses (protocol 4
to 6 mg/kg intramuscularly; median dose 300 mg) as
rescue therapy for agitated adults who had failed initial
tranquilization attempts, usually with 2 sequential doses
of droperidol 10 mg intramuscularly. Ketamine worked
remarkably well, inducing adequate sedation in 44 of 49
patients, with 4 of the 5 failed sedations hampered by
underdosing of ketamine. This new study conrms past
smaller or less rigorous reports5-19 that ketamine is a highly
effective way to immobilize patients with acute behavioral
disturbance (Table). It works.
But is it safe? We might logically presume so, given the
exceptional safety record of ketamine for ED procedural
sedation4,20 and the lack of serious adverse events in the
current report.2 However, an agitated and physiologically
deranged patient is very different from an otherwise healthy
patient needing a fracture reduction, and previous reports
of patients receiving ketamine for agitated behavior (Table)
describe hypoxia, laryngospasm, the need for intubation,
and hallucinatory recovery reactions. The specic adverse
event descriptions in these reports lack important detail
but are worrisome nonetheless.
The combative, delirious, agitated patient is likely to
be experiencing an extraordinary surge of endogenous
(and often exogenous) catecholamines.1 Is it wise to then
administer ketamine, a drug that is sympathomimetic by
inhibiting reuptake of these catecholamines? The mild to
moderate increases in blood pressure, pulse rate, and
cardiac output resulting from ketamine are well tolerated in
healthy patients.4 But in someone already pushed to the
brink with sympathetic overactivation, could adding
ketamine to the mix induce dysrhythmias, myocardial
ischemia, or hypertensive emergencies?21 Consider the
analogy of the TASER neuromuscular incapacitating device
widely used by law enforcement: the electrical shocks from
this tool are very safe in healthy volunteers; however, they
can occasionally precipitate fatal cardiac arrest in actively
combative and violent individuals.22 Sudden death has
been described with recreational ketamine abuse23-25 and
is known to occur in patients with excited delirium,1
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Ketamine Blow Dart

Table. Reports of ED or out-of-hospital ketamine administered primarily for acute behavioral disturbance or combativeness, alone or
superimposed on underlying illness or trauma.
Report

Patients
5

Efcacy

2001 Roberts
2004 Porter6
2005 Hick7
2007 Melamed8
2007 Svenson9
2012 Burnett10,11

1 ED adult
2 out-of-hospital adults
1 out-of-hospital adult
5 out-of-hospital adults
4 out-of-hospital adults
13 out-of-hospital adults

Effective
Apparently effective
Effective
Effective
Apparently effective
Apparently effective

2012 Le Cong12
2013 Ho13
2014 Pritchard14
2014 Scheppke15

19 out-of-hospital adults
2 out-of-hospital adults
1 out-of-hospital adult
52 out-of-hospital adults

Effective
Effective
Effective
50 of 52 sedated

2015 Burnett16

51 out-of-hospital adults

Apparently effective

2015 Hopper17
2015 Keseg18

3 ED children and 29 ED adults

35 out-of-hospital adults

20 of 32 required additional sedatives

32 of 35 sedated

2016 Kowalski19
2016 Isbister2

5 ED adolescents
49 out-of-hospital adults

Effective
44 of 49 sedated

particularly when violent struggle occurs. Given that

ketamine is likely to become more widely used for this
indication, it seems inevitable that rare cases of serious
cardiovascular complications, including cardiac arrest, will
occur. It is sobering to note that these patients toxic
pathophysiology predisposes them to serious morbidity and
sudden death, whether ketamine is used or not. No such
life-threatening cardiovascular complications were observed
with ketamine in the current2 or previous5-19 studies
(Table); however, the aggregate sample size for this
previous research is insufcient to ensure safety.
Laryngospasm is a rare but well-established adverse effect
of ketamine.3,20 One of the patients treated by Burnett
et al10,11 developed recurrent laryngospasm associated with
severe hypoxia (oxygen saturation 20%), which responded
to bag-valve-maskassisted ventilation and ultimately led to
intubation to secure his airway. Scheppke et al15 describe 3
occurrences of signicant respiratory depression in
patients who received both ketamine and midazolam, with
2 receiving intubation and 1 assisted ventilation. A stable
airway is typical of ketamine sedation, and in this series no
patient who received ketamine alone experienced
respiratory depression. However, this stability is by no
means guaranteed.
Burnett et al10 describe emergence reactions in 3
ketamine-treated patients. Corroboratory details are not
provided; however, all 3 were inebriated and 1 had known
schizophrenia. Ketamine-induced hallucinatory reactions
are not as rare in adults as they are in children and can be
frightening or nightmarish.3,26 When used for acute
2 Annals of Emergency Medicine

Serious Adverse Events

None
None
None
None
None
3 hypoxia, 1 recurrent laryngospasm leading to
intubation, 1 hypersalivation, 3 emergence
reactions
None
None
None
3 signicant respiratory depression, 2
treated with intubation and 1 with assisted
ventilation
14 intubations, but believed unrelated to
ketamine
None
8 intubations, but believed unrelated to
ketamine
None
None

behavioral disturbance, ketamine may readily exacerbate

the underlying psychopathology of an already troubled
patient. With dissociative dosing (4 to 6 mg/kg), this is not
an immediate concern but one that should be anticipated as
dissociation later subsides. Ketamine procedural sedation
has been considered contraindicated in the setting of
psychosis,3 given that this drug is known to exacerbate
schizophrenic symptoms.27 However, this concern,
although legitimate, is not a life threat. Any short-term
adverse psychiatric effect from ketamine can be mitigated
or counterbalanced by the inevitable follow-up doses of
antipsychotics or benzodiazepines.
So should we administer ketamine to our next agitated
and potentially violent patient? It depends. Several of the
previous reports (Table) used ketamine as a rst-line agent.
Isbister et al2 instead used ketamine as rescue for agitated
patients refractory to 2 doses of droperidol, ultimately just
1.5% of their sample, ie, the worst of the worst.
Rather than considering any medication or cocktail as
always rst line or always second line, it probably makes
more sense to make the call on a case-by-case basis.
Tranquilization with traditional antipsychotics can be
attempted for individuals with some degree of control or
cooperation. When your patient is truly an imminent safety
threat to your staff and to themselves, however, the
literature evidence is clear that a hefty shot of ketamine
should take em down quickly and effectively and seems
safer than an alternative strategy of succinylcholine
intramuscular with crash intubation. Rapid behavioral
control also prevents continued struggle against physical
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Ketamine Blow Dart

restraints and allows treatment of unstable medical

conditions to proceed expeditiously.
Once the decision to use ketamine is made, it is
important not to be stingy. Administer a full 4 to
6 mg/kg because underdosing of ketamine risks
incomplete dissociation, which may be ineffective and
counterproductive. Use multiple injections as needed to
rapidly deliver the required volumeright through
clothing if necessary. The onset of dissociation is typically
2 to 5 minutes, with additional dosing to achieve control
rarely necessary unless underdosing has occurred.2 Once
immobilization is achieved, exposure, monitoring, and
the application of restraints can be initiated while
providers stand by for laryngospasm or other emergency
airway support. As your resuscitation and diagnostic
evaluation proceeds, recognize that the ketamine effect
will soon wane and generous follow-up antipsychotics
or benzodiazepines are likely to be required.
In summary, ketamine intramuscularly is highly effective
for the rapid control of agitated and violent patients and,
although not devoid of risks, may represent the best option
when there is truly an imminent threat to patient and
caregiver safety. In this circumstance, ketamine appears
much more likely to get you out of trouble than to cause
trouble. Bring on the blow darts!
Supervising editor: Michael L. Callaham, MD
Author afliations: From the Department of Emergency Medicine,
Loma Linda University Medical Center and Childrens Hospital,
Loma Linda, CA (Green); and the Emergency Department, Lions
Gate Hospital, North Vancouver, British Columbia, Canada
(Andolfatto).
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, nancial, and other relationships
in any way related to the subject of this article as per ICMJE conict
of interest guidelines (see www.icmje.org). The authors have stated
that no such relationships exist.
Dr. Callaham was the corresponding editor on this article.
Dr. Green did not participate in the editorial review or decision to
publish this article.

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