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Ketamine Works First-Line for Agitation

March 20, 2017

Short Attention Span Summary

Is anyone surprised a horse tranquilizer works in agitated patients?
There isn’t much published about ketamine first-line for agitated patients.  This observational study found that a median dose of 1 mg/kg IV or 3 mg/kg IM ketamine (compared to midazolam 3mg IV/2.2mg IM, lorazepam 2mg IV/2.4mg IM, haloperidol 6mg IM, or haloperidol/lorazepam 5mg/2mg) was far more effective at reducing agitation at 5, 10, and 15 minutes.  And there was no increase in adverse effects.  Ketamine was surprisingly hemodynamically neutral, given its intrinsic sympathomimetic properties.  Likely the agitation reduction and sympathetic stimulation from the drug cancelled out any net effect.

Spoon Feed
Ketamine appears to be a very effective and safe first-line drug for agitated patients in the ED. PharmERToxGuy has an outstanding summary of this article.


Am J Emerg Med. 2017 Feb 13. pii: S0735-6757(17)30114-6. doi: 10.1016/j.ajem.2017.02.026. [Epub ahead of print]

Ketamine as a first-line treatment for severely agitated emergency department patients.

Riddell J1, Tran A2, Bengiamin R3, Hendey GW4, Armenian P3.

Author information:

1Division of Emergency Medicine, University of Washington, Seattle, WA, USA. Electronic address: jeffridd@uw.edu.

2St. Louis University School of Medicine, USA.

3Department of Emergency Medicine, University of California San Francisco – Fresno, Fresno, CA, USA.

4Department of Emergency Medicine, University of California Los Angeles, Los Angeles, CA, USA.



Emergency physicians often need to control agitated patients who present a danger to themselves and hospital personnel. Commonly used medications have limitations. Our primary objective was to compare the time to a defined reduction in agitation scores for ketamine versus benzodiazepines and haloperidol, alone or in combination. Our secondary objectives were to compare rates of medication redosing, vital sign changes, and adverse events in the different treatment groups.


We conducted a single-center, prospective, observational study examining agitation levels in acutely agitated emergency department patients between the ages of 18 and 65 who required sedation medication for acute agitation. Providers measured agitation levels on a previously validated 6-point sedation scale at 0-, 5-, 10-, and 15-min after receiving sedation. We also assessed the incidence of adverse events, repeat or rescue medication dosing, and changes in vital signs.


106 patients were enrolled and 98 met eligibility criteria. There was no significant difference between groups in initial agitation scores. Based on agitation scores, more patients in the ketamine group were no longer agitated than the other medication groups at 5-, 10-, and 15-min after receiving medication. Patients receiving ketamine had similar rates of redosing, changes in vital signs, and adverse events to the other groups.


In highly agitated and violent emergency department patients, significantly fewer patients receiving ketamine as a first line sedating agent were agitated at 5-, 10-, and 15-min. Ketamine appears to be faster at controlling agitation than standard emergency department medications.

Copyright © 2017 Elsevier Inc. All rights reserved.

PMID: 28237385 [PubMed – as supplied by publisher]

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