Ketamine in ER for agitated patients more effective than traditional methods

Treatment of highly agitated or violent patients in the emergency department with the sedative ketamine is more effective than traditional approaches, and could be safer for patients and staff. These results are from an innovative clinical trial led by Centre for Health Evaluation & Outcome Sciences (CHÉOS) Scientist Dr. David Barbic and published this week in Annals of Emergency Medicine.

Standard drugs can increase risk for other health issues

The study compared the effectiveness of ketamine to midazolam and haloperidol, a benzodiazepine and antipsychotic combination commonly used in emergency departments in these circumstances.

Midazolam and haloperidol are effective, but can increase the risk of respiratory and neurological issues.

Dr. David Barbic

“We see patients presenting to the emergency department agitated, aggressive, and with potentially violent behaviour every day,” says Dr. Barbic. “Previous research suggested that ketamine could be quicker and safer but we needed a randomized trial to be sure.”

With support from CHÉOS Project Manager Leslie Love and Statistician Hong Qian, Dr. Barbic and his team, which includes CHÉOS Scientists Drs. Brian Grunau, Frank Scheuermeyer, Hubert Wong, and Skye Barbic, launched the Rapid Agitation Control with Ketamine in the Emergency Department Study in the spring of 2018.

Over the next two years, the study enrolled 80 severely agitated patients at St. Paul’s Hospital’s Emergency Department. Patients were randomized to receive either ketamine or the standard treatment of midazolam and haloperidol, both via injection. Patients were then monitored and underwent standardized testing, including blood screening and ECG.

Researchers tracked time for patients to become sedated

The researchers were primarily looking at how long it took for patients to become adequately sedated in order to receive appropriate care, but they also looked at adverse events and the need for additional sedative medications.

Improved staff and patient safety paramount in ED

“The patients who were given ketamine were sedated much faster,” notes Dr. Barbic. Their median time to sedation was almost nine minutes earlier than for patients treated with midazolam/haloperidol. Anecdotally, Dr. Barbic says this shorter time to sedation probably translates to improved safety for hospital staff and other patients.

“Patient safety is paramount in the emergency department. Any development or innovation that we can utilize to provide more effective, safer care is something worth exploring,” he says.

Unfortunately, the researchers had to stop enrollment early due to the COVID-19 pandemic so they are not able to fully compare the safety of the two medications. Although there were not enough patients to comment definitively, the researchers didn’t see a statistically significant difference in serious adverse events between the two study groups.

“We know that some emergency physicians across North America are already using ketamine as their first-line treatment in these instances but this study provides confirmation that this may in fact be a better option,” adds Dr. Barbic.

He was recently awarded the Grant Innes Research Paper and Presentation Award from the Canadian Association of Emergency Physicians (CAEP) for his abstract submission for this study. It was presented at the first plenary session on June 16 at the annual CAEP conference.

This story was originally published on the CHÉOS website.