The panel discussed the critical importance of monitoring the patient after ketamine is administered. In its view, most adverse events that result from ketamine use in the prehospital setting are avoidable if EMS agencies and paramedics prioritize immediate, proactive monitoring and resuscitation protocols at the patient’s side.
In general, EMS providers initiate patient monitoring after the patient is loaded into the ambulance. The panel was concerned that delayed monitoring can lead to negative outcomes when ketamine is administered, particularly if the patient’s airway has been compromised. The panel therefore concluded that delayed monitoring is unacceptable. Paramedics must immediately initiate monitoring at the patient’s side once ketamine is administered.
To do this, paramedics must take the gurney and equipment necessary to monitor and resuscitate airway and/or cardiac arrest to the patient’s location as soon as the paramedic decides to administer ketamine.[55] At minimum, the resuscitation equipment that must be transported to the patient’s side includes: airway equipment, suction, end tidal CO2 monitor, oxygen, pulse oximeter, blood pressure cuff, EKG monitoring, and IV/IO access supplies.
Because of the overriding importance of maintaining the patency of the patient’s airway, the panel recommends that waveform capnography should be conducted patient-side first. Capnography monitors measure the end-tidal carbon dioxide (ETCO2), or the amount of carbon dioxide that a patient exhales, and indirectly measures respiratory and cardiac function. Next, paramedics must measure the peripheral capillary oxygen saturation (SpO2). SpO2 indicates the level of oxygen in the blood. After this, the paramedic must obtain the patient’s blood pressure, monitor cardiac rhythm, and secure IV or IO access as soon as possible. Fluids should be administered when appropriate.[56]
There was some discussion about how paramedics should assist patients who are having trouble breathing on their own. The panel deemed jaw thrust and chin lift maneuvers to be effective for most patients, but clarified that some patients may need greater respiratory support when indicated (e.g., bag-valve-mask, intubation). The medical rule of thumb that is often used to determine whether to intubate a patient who may be in respiratory distress is the Glascow Coma Score (GCS), a metric that assesses the level of responsiveness of a patient. If the patient’s score is equal to or less than 8, the medical practitioner should consider intubation. However, the panel noted that this rule is not necessarily applicable for ketamine administration: the dissociative state often leads to a GCS < 8, yet intubation may not be required. In these cases, the paramedic should consider the ETCO2 and SpO2 readings as guideposts in deciding whether intubation is warranted. Often, augmenting ventilation and ensuring adequate oxygenation may abate the need for intubation.
Because the panel determined that there is insufficient focus on patient monitoring after ketamine administration, it recommends that EMS agencies should adopt these specific monitoring steps as protocol. The panel notes that the monitoring described in its recommendation is in addition to, and does not replace, all other routine monitoring that paramedics must conduct.
PANEL RECOMMENDATIONS:
Most adverse events that result from ketamine use in the prehospital setting are avoidable if EMS agencies and paramedics prioritize immediate, proactive monitoring and resuscitation protocols at the patient’s side.
The necessary monitoring and resuscitation equipment should be brought to the patient’s side prior to administering ketamine.
End tidal CO2 monitoring with waveform capnography should be the first step in monitoring a patient after ketamine administration in the field so that cardio/respiratory compromise can be quickly identified and managed.