A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting - 22/10/24

Doi : 10.1016/j.annemergmed.2024.09.003

Maeve Muldowney, MBBCh, BAO ^a,^⁎ , Catherine R. Counts, PhD, MHA ^b,^c, Madison C. Maider ^d, Sam R. Sharar, MD ^a, Andrew M. McCoy, MD, MS ^b, Rajen Nathwani, MBBS ^a, Jessica J. Wall, MD, MPH ^b,^e, Killian Pache ^b, Charles Maynard, PhD ^f, Thomas D. Rea, MD, MPH ^g,^h, Peter J. Kudenchuk, MD ^h,ⁱ, Michael R. Sayre, MD ^b,^c
^a Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
^b Department of Emergency Medicine, University of Washington, Seattle, WA
^c Seattle Fire Department, Seattle, WA
^d University of Washington School of Medicine, Seattle, WA
^e Department of Pediatrics, Division of Emergency Medicine, Seattle, WA
^f University of Washington School of Public Health, Seattle, WA
^g Department of Medicine, University of Washington, Seattle, WA
^h Division of Emergency Medical Services, Public Health, Seattle & King County, Seattle, WA
ⁱ Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Tuesday 22 October 2024

Abstract

Study objective

Acute behavioral disturbance is characterized by altered mental status and psychomotor agitation. Pharmacological sedation may be required, risking potential respiratory compromise. We compared the need for emergent airway support following administration of midazolam or ketamine to treat acute behavioral disturbance in the out-of-hospital setting.

Methods

In this retrospective cohort study of patients with acute behavioral disturbance in an urban emergency medical service system between 2017 and 2021, we compared the likelihood of out-of-hospital advanced airway management following administration of midazolam or ketamine. Advanced airway management was defined as out-of-hospital endotracheal intubation or supraglottic airway insertion.

Results

Among 376 eligible patients, the median age was 35, and 78% were men. The most common etiologies of acute behavioral disturbance were substance use (51%), trauma (18%), and presumed postictal agitation (11%). In all, 162 patients (43%) initially received midazolam and 214 (57%) ketamine. The frequency of advanced airway management was similar between these respective groups (12% [n=19] versus 11% [n=24], difference 0.5%, 95% CI −6.0% to 7.0%). Adjusted for potential confounders, the odds of receiving advanced airway management did not differ between midazolam and ketamine (aOR 1.02, 95% CI 0.44 to 2.38), and no differences were observed in emergency department intubation rates (14% in midazolam recipients, 11% for ketamine) or overall mortality (2% in midazolam recipients, 1% for ketamine).

Conclusion

In this cohort study of patients with acute behavioral disturbance, emergent airway support and other outcomes did not differ following out-of-hospital treatment with midazolam or ketamine.

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Plan

Introduction

Background

Importance

Goals of the Investigation

Materials and Methods

Study Design and Setting

Setting

Selection of Participants

Characteristics of Study Participants

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: MMu, RN, SRS, AMM, MRS, TDR, PJK, and CRC conceived of the study design. MMu, JJW, and CRC obtained Institutional Review Board approval. MCM, JJW and CRC abstracted the data. CRC, KP, and CM analyzed the data and all authors were involved in its interpretation. MMu drafted the initial manuscript and all authors contributed substantially to its review and revision. All authors have approved this final version. MRS takes responsibility for the paper as a whole.
	Data sharing statement: Partial or complete datasets and data dictionary are available from date of publication until 3 years after publication, on request to Dr. Catherine Counts at crcounts@uw.edu, by investigators who provide an IRB letter of approval.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). This project did not receive external funding. All authors report no relevant conflicts of interest.
	Presentation information: This work was presented, in part, at the Annual Meeting of the National Association of EMS Physicians, Tampa, Florida in January 2023.