Ketamine Blow Dart for refractory agitated delirium = procedural sedation
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You may have heard about ketamine for agitated delirium and you would like to start "taming the tigers" in your ED who have shrugged off multiple rounds of versed and antipsychotic.
This is a great use for our beloved ketamine and two recent articles in the annals of EM really show you how to do it. Steve Green's editorial is a particularly useful how-to.
4-5mg kg IM is the go to dose.
But as the regulatory eagles ?buzzards circle ever closer on our practice, what is the dart? Is it analgesia?, anxiolysis? If it is procedural sedation then what is the procedure?
An informal pole of some the bright lights in emergency medicine suggests the safest and most appropriate way to practice is:
Continue considering the 5mg IM versed ( or other benzo as a light sedation ) No need to break out the packet or fire up the EMR sedation module for this...whew!
BUT...when upping the ante with the dart of ketamine at the 4-5mg/kg IM, (often after who know how much preceding medication), bite the bullet and consider this a bona fide "procedural sedation."
Documentation:
1. You can skip all the pre-sedation evaluation due to urgent patient need.
( Sir, I see you are trying to eat through the straps on your arm, but could you tell me when last ate?)
2.The procedure is "immobilization for safety."
3. Monitor and document as you would any other sedation, ideally with ETCO2 & and pulse ox. Pay special attention to prevention of mechanical obstruction. (The idea is with ketamine you will keep breathing but may not have the muscle tone to independently straighten out the neck to keep the airway patent.)