Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial

Area of Science:

• Emergency Medicine
• Pharmacology
• Psychiatry

Background:

• Severe psychomotor agitation in emergency departments (EDs) requires rapid and effective behavioral control.
• Current treatments, like midazolam and haloperidol, may have limitations in speed of onset or efficacy.
• Intramuscular ketamine is explored as a potentially faster-acting alternative.

Purpose of the Study:

• To compare the time to adequate sedation between intramuscular ketamine and a combination of midazolam and haloperidol.
• To evaluate the safety and efficacy of these agents in managing severe agitation in ED patients.

Main Methods:

• A randomized clinical trial involving 80 ED patients with severe agitation (Richmond Agitation Score ≥+3).
• Patients received either intramuscular ketamine (5 mg/kg) or intramuscular midazolam (5 mg) plus haloperidol (5 mg).
• Primary outcome was time to adequate sedation (RASS ≤-1); secondary outcomes included rescue medication use and serious adverse events.

Main Results:

• Ketamine achieved adequate sedation in a median of 5.8 minutes versus 14.7 minutes for midazolam/haloperidol, a difference of 8.8 minutes.
• The ketamine group showed a significantly shorter time to sedation (Hazard Ratio 2.43).
• Serious adverse events occurred in 12.5% of the ketamine group and 5.0% of the midazolam/haloperidol group.

Conclusions:

• Intramuscular ketamine provides a significantly faster onset of adequate sedation compared to midazolam and haloperidol for agitated ED patients.
• Ketamine represents a more rapid therapeutic option for managing severe psychomotor agitation in emergency settings.
• Further research may explore long-term outcomes and specific adverse event profiles.