Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What I Wanted from EMS Santa But Did Not Get

Yesterday, I mentioned a bunch of things that are good, but not at the top of my list. This is what I really wanted. Maybe during my shift last night, when I heard hoof beats on the roof, I shouldn’t have thought of horse or zebras.

There is one change to my protocols that probably would not be used often, but when used would more than make up for the lack of use.

What did this rogue want?


Is it safe?

Ketamine is safe.

Is it effective?

Ketamine is effective – for many different conditions.

Image credit.

Excited delirium – IM (IntraMuscular) injection that works in a few minutes and is predictable in absorption.[1]

Airway management – IM or IV and the patient will not fight with a cannula or mask. Also can be used for intubation, although a paralytic would be best to go with it. The stomach contents should remain in the stomach – and we should assume that the stomach is full of chili and beer. Paralytics keep the stomach contents from migrating.[2]

Cardioversion – since we do not carry any effective antiarrhythmics (we have amiodarone and lidocaine – they are about as effective as placebo), we should be sedating patients in preparation for elective cardioversion in the ED, with the ability to emergently cardiovert them if they suddenly deteriorate. Ketamine is less likely than other sedatives to drop the cardiac output.[3]

Pain management – Ketamine alone is used for surgery in some places without complications and without complaints of being awake and feeling the surgery. Ketamine allows the patient to maintain airway reflexes.

DSI – Another abbreviation? RSI, DFI, CFI, and now DSI? Yes. DSI (Delayed Sequence Intubation). The best airway is the one maintained by the patient with intact airway reflexes. Ketamine can allow that to happen.[2]

Imagine the patient who has a neck so short that it seems his head is being sucked into his torso, but he is breathing on his own. We could knock him down and play around with his oropharynx until he has more lunch in his lungs than oxygen, but that would not be good airway management. We could use ketamine and oxygen by mask (maybe with 15 LPM oxygen by cannula in addition to the mask) and transport him to someplace where intubation (if necessary) can be done in a more controlled environment. And when the emergency physician grabs for the video laryngoscope, that is an admission that the right decision was made.

I know. I am crazy to think that anyone would let EMS do this.

In some places, EMS is already doing this. Safely and effectively.

Maybe I am not so crazy, but I still do not have ketamine to help my patients.


[1] On Human Bondage and the Art of the Chemical Takedown
November 13, 2011
Page with podcast and supplemental information

[2] Delayed Sequence Intubation (DSI)
January 31, 2011
Page with podcast and supplemental information

[3] Procedural Sedation – Part I
July 26, 2010
Page with podcast and supplemental information



  1. Our service has been using Ketamine for almost two years and it has saved many lives and eased a lot of discomfort. Excited delirium patients don’t stand much of a chance without it. It facilitates extrication of critical patients who are still awake and who often have compound fractures. Given the choice of struggling to hold a combative head patient down while trying to get them in a c-collar and a backboard vs. IM Ketamine and a cooperative patient within a minute or two, Ill take the latter. It’s a beautiful thing when used responsibly. It certainly is safer than trying to sedate and paralyze a hypoxic patient.

  2. Funny, I’ve used Lidocaine and Amiodarone a number of times to terminate antiarrhythmias, although I still contend that Lidocaine works better than Amio. I’ve only used cardioversion a couple of times and only when there was no other alternative. The last time I used it, we were using Valium for sedation, it’s been that long.

    Amiodarone works just as well as Ketamine for sedation, Versed or Ativan work better for excited delirium.

    Fentanyl probably works better for pain management, especially cardiac related pain.

    I’m not following the last part of you post, because you haven’t set the circumstances requiring Ketamine and a NRB.

    Ketamine might be an all in one wonder drug, but why do we need an all in one wonder drug when we can have a selection of wonder drugs?

    • I’m not too familiar with Ketamine, so I will have to read up. As to the lido/amio comment, I am glad to see someone at least has the same memories. I’ve used both, and have never seen amio terminate anything. And as to cardioverting, the last time I did one was in 1998. Yep, we used Valium, too. Funny thing, the electricity didn’t work. 100mg lido broke the VT. I know, I know, anecdotal and all that…

  3. Come work with me at hcec in Houston. We have some very progressive medical guidelines and always looking to improve. Been using Ketamine for a year for excited delirium, severe trauma, control of combative patients, rapid sequence airway, and asthmatics. Merry Christmas! Ho, Ho, Ho….