Prehospital Ketamine Administration: What, When and Why?

by | March 4, 2022

Over the last several years, ketamine has begun making the rounds in court and on the news increasingly more frequently. With law enforcement and fire/EMS at the center of the issue, we need to ask the question: Why has ketamine become such a hot topic since the mid-2010s? Is ketamine safe to use in a prehospital environment? If so, when and for what reason? And for EMS professionals, how and how much should be administered? Understanding when—and when not—to administer ketamine and how to do so safely is essential training for first responders.

In a recent webinar, Dr. Brent Myers, Chief (Ret.) Mike Ranalli and Deputy Chief Curt Varone discussed the issue of ketamine from a range of critical perspectives: medical, fire/EMS and law enforcement. A multidisciplinary approach to understanding ketamine administration is key to ensuring the safety of first responders, patients and the public.

Ketamine: Why or Why Not?

First, a quick recap: What makes ketamine potentially unsafe? “ is so successful sometimes…the next thing you know, we’re applying it in a more casual way instead of in a very deliberate way, really thinking through the appropriateness of it,” explains Deputy Chief Varone. But ketamine (and other sedatives like it) shouldn’t be a catch-all, as it can present a significant risk to patients, especially in the prehospital environment. Determining the correct dosage for a patient in the field can be a challenge—and the risk associated with overdosing is great. The proper intramuscular dosage for ketamine, depending on local paramedic protocols, is based on the patient’s weight, but quickly and correctly estimating the patient’s weight is not always a simple task.

Many patients who receive ketamine are also typically in an already elevated and agitated state, putting them at high risk of respiratory distress or another medical emergency even without the addition of a sedative. Ketamine administration on its own can elevate the patient’s risk of hypoxia and hypercarbia. “Immediate, post-sedation monitoring—we need to see that every time,” emphasizes Dr. Myers, as reduced respiratory rates and decreased levels of oxygen in the body can present risk of severe injury or death to the patient. But with the proper monitoring, EMS professionals can address these potential problems before they arise.

Assessing the Need for Prehospital Ketamine

While ketamine can certainly be a useful and effective tool for paramedics to support other first responders when dealing with agitated subjects, it’s just that—one tool. Due to the risks associated with ketamine administration, we should not use it before determining a suitable plan for its safe administration. Ketamine should be reserved for medical situations that require sedation—not simply to assist law enforcement in apprehension or restraint. When administered, it must be done so carefully and with constant monitoring of the patient. As Dr. Myers explains, “If require this level of sedation, they require a hospital evaluation to follow. If you don’t think they need that, then they probably don’t need the sedation to begin with.”

Always remember that sedation is never to be used solely for the purposes of law enforcement custody issues or to prevent an agitated state.

Because ketamine is often used in situations with the “hot, sweaty, naked guy,” or a patient suffering from an extremely agitated state, it can be a critical tool to control the subject, keeping them from harming themselves or others. “Bringing in a control allows us to determine what caused the situation and make sure we don’t have bad outcomes,” says Dr. Myers. “Sedate and evaluate.” An important note: Ketamine should only be used when paramedics deem it necessary and have a set plan of action in place. Law enforcement professionals do not have authority to order paramedics to administer ketamine or any other medical intervention.

“Law enforcement’s response is behavior-based; it’s what you’re seeing. You’re not there to diagnose the person. Your job is not to direct EMS, but to describe the behavior,” says Chief Ranalli. Instead, law enforcement and fire/EMS personnel should work together to determine the best course of action for the safety of the subject, the first responders and the general public, whether or not that involves the administration of a sedative such as ketamine.

Mitigating the Risk of Prehospital Ketamine

Understanding that prehospital ketamine administration can pose a considerable risk, what steps can we take to prevent tragedy and keep it as a safe and effective tool in our toolkit? First, the responding law enforcement officers must assess the situation from a safety and behavioral perspective. The better law enforcement professionals describe the situation and prior circumstantial evidence, the better fire/EMS professionals can develop and execute a plan to medically address it.

Fire/EMS response in these situations must rely on proper training, policy and procedure. It all goes back to training, training, training. Always remember that sedation is never to be used solely for the purposes of law enforcement custody issues or to prevent an agitated state. Ketamine can be used when the subject is already in an agitated state and a danger to themselves and others.

Prehospital ketamine administration can be made safer and more effective when a proper approach is planned by all responding parties. “We’ve got to have those lines of communication open,” says Deputy Chief Varone. “Before fire/EMS makes a decision on what our course of action is going to be, we have to understand what’s going on.” Interagency communication before and during an event can make all the difference. Have adequate resources on hand and make a plan before approaching an agitated subject.

Ketamine, when used safely and appropriately, can save lives. Law enforcement must understand their role and limitations, and EMS professionals must be diligent about post-sedation and monitoring activities to avoid harm resulting from ketamine administration.

To learn more, watch “Agitated Subjects and Ketamine: Working Together to Enhance Safety,” on-demand.

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