Ketamine For Anger Management

From the land of “we still have droperidol”, this case series details the use of ketamine as “rescue” treatment for “agitated delirium”.  In lay terms, the situation they’re describing is the utterly bonkers patient being physically restrained by law enforcement for whom nothing else has worked.

In this case series, which represented only 49 of 1,296 patients with acute agitation, intramuscular ketamine was used as second- or third-line therapy behind droperidol and benzodiazepines.  Target dosing was 4-6 mg/kg, similar to procedural sedation.  Of the 49 requiring rescue ketamine, 44 were effectively sedated within 120 minutes – with a median time to sedation of 20 minutes.  The patients who were not adequately sedated with their initial dose of ketamine almost all received deliberate underdosing out of concern for potential respiratory impairment.

Three patients suffered adverse effects – two with vomiting, and one with desaturation 40 minutes after ketamine.  As with any observational series without a control, particularly a small one, little can be conclusively stated regarding the safety.  However, it is reasonable to consider any potential harms from such large doses of ketamine in the context of the harms of alternative sedating agents or injuries from continued agitation.

It may even be worth trying on the big green guy.

“Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/26899459

6 thoughts on “Ketamine For Anger Management”

  1. Ketamine was a drug of abuse, and now used to treat everything, talk to your damn patients calm them down and you can avoid this knee jerk, sedate first ask questions later whilst risking side effects, response ,that seems to be coming the Norm, someone should start publishing a how to calm your patients down without drugs as the first line

  2. A good point. Scott Seller runs a dedicated psych-only ED in Alameda County, and I heard him speak a few weeks ago. They definitely have some approach that reduces the need for sedation.

    That said, the skills for such an approach might not be prevalent in Emergency Medicine (I don't have them), and pharmacologic therapy is sometimes necessary.

  3. Agree largely, however let's not throw this baby out with the bathwater. If we stopped using all drugs with abuse potential, we'd be inhuman.

  4. Agree largely, however let's not throw this baby out with the bathwater. If we stopped using all drugs with abuse potential, we'd be inhuman.

  5. In the subset of patients that are excited delirium, you cannot talk them down, it's part of the syndrome.

    Looking at this study, this is a small number of folks that got the drug. As with anything in medicine, multi-drug therapy only increases risk. I still have not used a secondary med when doing behavioral sedation with ketamine. 3 adverse reactions is tiny. Don't forget vomiting in and of itself is not typically life threatening. Desaturation 40 mins after receiving ketamine makes me think something else was on-board or in this patients system. Ketamine alone is not a respiratory depressant – however the underlying disorder may be. In this subset, only the worst of the worst got the drug and it performed damn well I'd say.

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