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Ketamine does not appear to increase the risk of serious adverse effects compared to other medications in the prehospital setting, except for a potentially higher rate of intubation and severe oxygen desaturation with ketamine when used for acute behavioral disturbance. However, evidence is limited by methodological weaknesses, and variability in co-interventions, comparators, and outcome definitions. Evidence on mortality was limited to 3 studies with varying populations, comparators, and outcome definitions and should be considered preliminary.
Ketamine is an FDA-approved medication for procedural sedation and induction of general anesthesia that is also increasingly used for off-label indications including acute pain and acute behavioral disturbances. Ketamine is widely implemented across national EMS protocols, but concerns around safety and potential overuse or inappropriate use in the prehospital setting remain. Existing reviews have examined the use of ketamine in prehospital settings, but have largely depended on studies conducted in the ED.
Among 1,652 articles, 49 studies met eligibility criteria, and 24 were prioritized as the most rigorous and informative evidence. Studies varied widely by ketamine indication, comparators, and outcomes. No significant differences in mortality were reported with ketamine compared to other medications, but this evidence was limited to 3 studies with variable populations, co-interventions, comparators, and outcome definitions. Rates of other serious adverse events were generally low and did not significantly differ with ketamine compared to other medications, with the exception of a higher rate of intubation and severe oxygen desaturation with prehospital ketamine use for sedation in behavioral emergencies. Higher dose ketamine led to increased rates of adverse effects among patients receiving prehospital ketamine for sedation or RSI. Future research utilizing large databases could help to confirm the safety of prehospital administration of ketamine and provide further insight into the potential risks of ketamine for sedation in acute behavioral disturbance.
Safety of Ketamine in the Prehospital Setting: A Systematic Review (Management Brief)
