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

- Rogue Medic

Is Ketamine an EMS Wonder Drug

Too Old To Work responded to my description of the benefits of keatamine in What I Wanted from EMS Santa But Did Not Get.

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.

That is why we ignore anecdotal evidence of benefit. When we look at numbers large enough to provide predictable results, the memories of good outcomes from amiodarone and lidocaine are found to be the result of statistical variation, or bad memory, or both. We tend to forget the times that our antiarrhythmics do not work for V Tach (Ventricular Tachycardia).

Different studies show that amiodarone is only 29% effective at terminating V Tach,[1] only 25% effective at terminating V Tach, [2], and only 15% effective at terminating V Tach within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29% effective.[3]

If we are not trying to convert the rhythm promptly, should we even consider V Tach an emergency? If lights and sirens only make a difference of a minute, or two, V Tach is obviously not a lights and sirens emergency. Maybe we need a treatment that works.

Over 60% of the patients were cardioverted, for which they should receive a sedative that does not produce/worsen hypotension. We might as well start acknowledging that our anecdotes often do not match reality.

When the patient is awake and alert with a systolic blood pressure of 70, should we give a vasodilator, such as midazolam, or should we give a drug that does not decrease cardiac output, such as ketamine?

Image credit.

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

Amiodarone can produce hypotension, arrhythmias, and cardiac arrest, but that is not the kind of sedation I want. Was this a typo?

Since you do not appear to have listened to any of the EMCrit podcasts I linked to, here is another opportunity to learn. Dr. Weingart describes the lack of effectiveness of benzodiazepines (midazolam [Versed], lorazepam [Ativan], and diazepam [Valium]). He does not discourage their use to minimize emergence reactions, but he does not suggest that they are appropriate as sole treatments for excited delirium, unless that is all you have available.[4]

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

Which is great – if the patient does not require doses that produce respiratory depression, or if the only pain we treat is cardiac pain. Let me quote from the anonymous comment that you followed, but do not appear have read.

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.

If we want to be very limited in our options, then we should not ask for ketamine from our medical directors.

If we do not like using safe drugs, then we should not ask for ketamine from our medical directors.

I am stating that we should ask for ketamine from our medical directors. Our patients deserve it.

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

I linked to the EMCrit podcast covering DSI (Delayed Sequence Intubation). I think that podcast more than adequately describes the circumstances in under 20 minutes.[5]

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?

No drug is a wonder drug.

Ketamine does a lot of things very well – better than the usual EMS drugs. We should not allow our lack of familiarity to discourage us from using this drug that is used frequently, safely, and effectively all over the world.

At Free Emergency Medicine Talks you should listen to Mel Herbert – Updates on Ketamine. Unfortunately, the video is not included, but the information is still very clear and very thorough.

Ketamine is recommended for use in the patient whose stomach is not empty when, in the judgment of the practitioner, the benefits of the drug outweigh the possible risks.[6]

You may only treat patients who have been fasting, but I end up with patients with full bellies. I would prefer better ways to keep the stomach contents out of the lungs.

Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.[6]

Is any other sedative that safe?


[1] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed – indexed for MEDLINE]

[2] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

[3] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed – indexed for MEDLINE]

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

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

[6] Ketamine Hydrochloride (ketamine hydrochloride) Injection, Solution, Concentrate
[Bedford Laboratories]

FDA Label



  1. What are the cost differences between ketamine and the other sedation drugs?

  2. Any idea on why this isn’t used in EMS in lots of cases? I see us being able to fully relieve pain and not have to worry about causing that nasty “hypoxia” diagnosed solely by way of Sp02% reading, unless I misunderstand.
    That being said, any idea if any stateside systems use this drug for pain control at all?