Agitated patients who present a danger to themselves or emergency medical services (EMS) providers may require chemical restraints. Haloperidol is employed for chemical restraint in many EMS services. Recently, ketamine has been introduced as an alternate option for prehospital sedation. On-scene time is a unique metric in prehospital medicine which has been linked to outcomes in multiple patient populations. When used for chemical restraint, the impact of ketamine relative to haloperidol on on-scene time is unknown.
Objective: To evaluate whether the use of ketamine for chemical restraint was associated with a clinically significant (≥5 minute) increased on-scene time compared to a haloperidol based regimen.
Patients who received haloperidol or ketamine for chemical restraint were identified by retrospective chart review. On-scene time was compared between groups using an unadjusted Student t-test powered to 80% to detect a ≥5 minute difference in on-scene time.
110 cases were abstracted (Haloperidol = 55; Ketamine = 55). Of the patients receiving haloperidol, 11/55 (20%) were co-administered a benzodiazepine, 4/55 (7%) received diphenhydramine and 34/55 (62%) received the three drugs in combination. There were no demographic differences between the haloperidol and ketamine groups. On-scene time was not statistically different for patients receiving a haloperidol based regimen compared to ketamine (18.2 minutes, [95% CI 15.7-20.8] vs. 17.6 minutes, [95% CI 15.1-20.0]; p = 0.71).
The use of prehospital ketamine for chemical restraint was not associated with a clinically significant (≥5 minute) increased on-scene time compared to a haloperidol based regimen.
Medical Services Performance Measures: Recommended attributes and indicators for system and service performance. National Highway Traffic Safety Administration (NHTSA). 2009. Available at: www.ems.gov/pdf/811211.pdf
Brice JH, Pirrallo RG, Racht E, Zachariah BS, Krohmer J. Management of the violent patient. Prehosp Emerg Care 2003;7(1):48–55.
Cheney PR, Gossett L, Fullerton-Gleason L, Weiss SJ, Ernst AA, Sklar D. Relationship of restraint use, patient injury, and assaults on EMS personnel. ibid. 2006;10:207–12.
Mechem CC, Dickinson ET, Shofer FS, Jaslow D. Injuries from assaults on paramedics and firefighters in an urban emergency medical services system. ibid. 2002;6:396–401.
Grange JT, Corbett SW. violence against emergency medical services personnel. ibid. 2002;6:186–90.
Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med 2002;40:625–32.
Bell MD, Rao VJ, Wetli CV, Rodriguez RN. Positional asphyxiation in adults: A series of 30 cases from the Dade and Broward County Florida Medical Examiner offices from 1982 to 1990. Am J Forensic Med Pathol 1992;13:101–7.
Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint‐associated cardiac arrest. A case series. ibid. 1999;6:239–43.
Stratton SJ, Rogers C, Brickett K, Grunzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med 2001;19:187–91.
Otahbachi M, Cevik C, Bagdure S, Nugent K. Excited delirium, restraints, and unexpected death: A review of pathogenesis. Am J Forensic Med Pathol 2010;31:107–12.
Weiss S, Peterson K, Cheney P, Froman P, Ernst A, Campbell M. The use of chemical restraints reduces agitation in patients transported by emergency medical service. J Emerg Med 2012;43(5):820–8.
Vilke GM, DeBard ML, Chan TC, et al. Excited delirium syndrome (ExDS): Defining based on a review of the literature. ibid. 2012;43(5):897–905.
Burnett AM, Salzman JG, Griffith KR, Kroeger B, Frascone RJ. The emergency department experience with prehospital ketamine: A case series of 13 patients. Prehosp Emerg Care 2012;16:553–9.
Spaite DW, Valenzuela TD, Meislin HW, Criss EA, Hinsberg P. Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care. Ann Emerg Med 1993;22:638–45.
Gratton M, Garza A, Salomone III JA, McElroy J, Shearer J. Ambulance staging for potentially dangerous scenes: Another hidden component of response time. Prehosp Emerg Care 2010;14:340–4.
Tintinalli JE. Violent patients and the prehospital provider. Ann Emerg Med 1993;22:1276–9.
Koran L, Sheline Y, Imai K, et al. Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatr Serv 2002;53(12):1623–5.
Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med 2000;18:390–3.
Smego Jr RA, Durack DT. The neuroleptic malignant syndrome. Arch Intern Med 1982;142(6):1183.
Di Salvo, Thomas G, O'Gara PT. Torsade de pointes caused by high‐dose intravenous haloperidol in cardiac patients. Clin Cardiol 1995;18(5):285–90.
Kupas DF, Wydro GC. Patient restraint in Emergency Medical Services Systems. Prehosp Emerg Care 2002;6(3):340–5.
Thomas Jr H, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med 1992;21(4):407–13.
Alexander J, Tharyan P, Adams C, John T, Mol C, Philip J. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. Br J Psychiatry 2004;185:63–9.
Clinton JE, Sterner S, Stelmachers Z, Ruiz E. Haloperidol for sedation of disruptive emergency patients. Ann Emerg Med 1987;16:319–22.
Martel M, Sterzinge, A, Miner J, Clinton J, Biros M. Management of acute undifferentiated agitation in the emergency department: a randomized double‐blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med 2005;12(12):1167–72.
Knott JC, Taylor DM, Castle DJ. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med 2006;47(1):61–7.
Martel M, Miner J, Fringer R, et al. Discontinuation of droperidol for the control of acutely agitated out-of-hospital patients. Prehosp Emerg Care 2005;9:44–8.
Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med 1997;15:335–40.
Le Cong M, Gynther B, Hunter E, Schuller P. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J 2012;29:335–7.
Dean BV, Stellpflug SJ, Burnett AM, Engebretsen KM. 2C or not 2C: Phenethylamine designer drug review. J Med Toxicol 2013:1–7.
Ho JD, Smith SW, Nystrom PC, et al. Successful management of excited delirium syndrome with prehospital ketamine: Two case examples. Prehosp Emerg Care 2013;17:274–9.
Burnett AM, Watters BJ, Barringer KW, Griffith KR, Frascone RJ. Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. ibid. 2012;16:412–4.