Written by Megan Hilbert
Spoon Feed
For prehospital acute behavioral disturbance, there was no association with worse outcomes when giving midazolam versus ketamine in the field.
Some calming juice for you…
Acute behavioral disturbance is defined as altered mental status with concurrent psychomotor agitation. This may be caused by intoxication, mental health crisis, hypoglycemia, postictal period, or traumatic brain injury. These are dangerous patients – both for prehospital providers and themselves. Physical restraint alone can increase risk of sudden death and it often take a long time to identify and treat the underlying cause. Currently, there is no optimal medication or standardized recommended dosing. This was a retrospective cohort study of a single EMS agency with a primary outcome of emergent out-of-hospital airway support. Local EMS guidelines were to treat behavioral disturbances with either 1-5mg IM or IV midazolam q2-5mins PRN (in consultation with physician) or 5mg/kg IM ketamine (max 500mg, no need for physician consultation unless giving IV). Secondary outcomes evaluated need for airway support in the ED, medication-associated hypoxemia (<90%), need for additional sedation, cardiac arrest, disposition from ED, ICU admission, duration of ventilation, and length of hospital stay. Ultimately, there was no statistically significant difference in the measured outcomes between first administration of midazolam or ketamine. Even when adjusting for age, sex, substance use, mental health etiology, and IM route of administration, the odds ratios were not statistically significant. The authors point out several limitations, including the retrospective and observational nature of the study, particularly the fact that drug selection was up to the discretion of the provider.
How will this change my practice?
It won’t directly impact me since I work in the hospital setting, but it informs my practice when providing medical control. And it is helpful for those who develop local EMS guidelines.
Source
A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2024 Oct 21:S0196-0644(24)01069-2. doi: 10.1016/j.annemergmed.2024.09.003. Epub ahead of print. PMID: 39436328
