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Patient-Side Care Recommendations

This section provides recommendations regarding the care that paramedics provide to the patient when administering ketamine in the prehospital setting. The panel emphasized that paramedics should begin monitoring immediately after the ketamine is given, instead of waiting until the patient is in the ambulance. 

B.1  Panel Recommendation: Indications for Chemical Restraint 

The panel determined that the benefits of administering ketamine in the prehospital setting outweigh the potential risks if the following indications are satisfied: 

  1. The patient’s ability to cause/effect serious, probable, and imminent bodily harm to him/herself or others prevents safe assessment, treatment and transport; and 

  2. Efforts at verbal de-escalation have failed; and 

  3. The paramedic independently determines the patient requires treatment and transport to the hospital; and

  4. The paramedic independently determines the patient needs to be chemically restrained for safe transport because less restrictive alternatives, including physical restraint, would be inappropriate, ineffective, or unsafe; and

  5. The paramedic is acting under the parameters of a standing order,* or a verbal order given by a physician; and

  6. The paramedic complies with all monitoring requirements as recommended by this panel in Recommendation B.4.

*Note: The panel understands that Colorado House Bill 21-1251 requires the paramedic to attempt to obtain a verbal order and that Section 26-20-104, C.R.S., the existing restraint law, requires paramedics to engage in telephone consultation with a physician and receive a verbal order to administer ketamine after determination that chemical restraint by ketamine is the least restrictive and most appropriate alternative available. The panel recommends that Section 26-20-104, C.R.S. as well as HB 21-1251 be revised to allow for standing orders. Until these laws are amended, however, the panel acknowledges that paramedics must comply with all verbal order requirements contained in those laws, including the recording and monitoring requirements set forth in Section 26-20-104(1)(d)-(h), C.R.S.    

B.2  Panel Recommendation: Pharmacology

Ketamine is a safe drug when used in accordance with the other recommendations described in this report regarding patient indications, dosing, monitoring, and paramedic training for chemical restraint.  

B.3  Panel Recommendation: Dosing  

Using a standard, fixed dose of ketamine for chemical restraint based on the patient’s body stature rather than a strictly weight-based dose is preferred by the panel members. Weight estimation can be difficult and inaccurate. Using a standard dose based on the patient’s body stature allows paramedics to focus their attention on the critical work of monitoring the patient for any complications associated with treatment, including signs of respiratory or cardiac depression. 
 

The panel concludes that administration of 300/400/500 mg of ketamine IM is a safe dose for the small/average/large male patient, respectively, and administration of 250/350/450 mg of ketamine IM is a safe dose for the small/average/large female patient, respectively, assuming appropriate patient-side monitoring and trained personnel to manage any complications that may arise. Estimating a person's weight is therefore simplified to determine if a patient is of small (< 25th percentile), average (25th - 75th percentile) or large (>75th percentile).
 

The panel also recommends that a single IM ketamine dose should be calibrated to restrain the patient adequately to avoid repeat, or multiple, doses that can lead to patient complications. If a second ketamine dose might be required, the panel recommends that the paramedic must contact the on-line medical control physician to discuss the plan and receive a verbal order to do so.   

B.4  Panel Recommendation:  Monitoring  

The panel concludes that the immediate monitoring of a patient who has received ketamine is of paramount importance to patient safety. Therefore, the panel recommends that paramedics should adhere to the following resuscitative efforts when ketamine is administered as a chemical restraint in the prehospital setting.


Immediately after administering ketamine, paramedics shall begin physiological monitoring, obtain peripheral vascular access, and perform a physical exam at the patient’s side, in the specified following order below:

  1. Waveform capnography and end-tidal carbon dioxide (CO2) via face mask or nasal cannula to ascertain continued adequate ventilation

  2. Peripheral capillary oxygen saturation (SpO2) 

  3. Blood pressure assessment and monitoring

  4. Cardiac monitoring 

  5. Intravenous (IV) or intraosseous (IO) access

  6. Assess Glasgow Coma Scale (GCS). If the GCS is ≤8, do not automatically intubate. Instead, confirm adequate ventilation and oxygenation. If 1 and 2 above are adequate, then intubation is likely unnecessary. If airway obstruction is present, reposition to improve airway patency and consider other assisted airway measures (nasopharyngeal/oropharyngeal airway) prior to intubation.