Background: Emergency providers frequently care for agitated patients ranging from restlessness to verbally and physically aggressive. Agitation is a symptom, not a diagnosis and these patients require careful evaluation to rule in or out serious medical conditions. Unfortunately, the agitation itself often obstructs this evaluation and places the patient, other patients and staff at risk. While verbal de-escalation can be effective in select cases, administration of medications for behavioral control is often required. Numerous medications are available for this indication, but the optimal approach is still unclear....Read More
Background: In recent years, ketamine use has dramatically increased in the Emergency Department (ED). There are four major indications for the use of ketamine in the ED: analgesia with low dose ketamine (LDK), induction for rapid sequence intubation, procedural sedation and sedation of the agitated patient. A number of relative contraindications for ketamine exist though many of them have been debunked through analysis of the evidence. This includes the dogma that ketamine cannot be used in patients with head trauma (for fear of increasing the ICP) or in patients with hypertension or tachycardia.
One contraindication that persists, though, is that of a history of psychiatric illness. Ketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist and it can produce a broad range of cognitive and behavioral disturbances including psychosis. These disturbances are short-lived in the majority of individuals but there is a fear that ketamine can cause decompensation of psychiatric illness. The ACEP Clinical Policy lists psychiatric illness as an absolute contraindication for dissociative sedation with ketamine (Green 2011)....Read More