Ketamine – a one-time horse tranquilizer now frequently used in medicine – is going under the microscope in Colorado.
The Colorado Department of Public Health and Environment (CDPHE) on Tuesday confirmed they are looking into the use of ketamine by health care professionals. In a statement, CDPHE said it “received numerous complaints, beginning on 6/24, that provided additional information regarding a ketamine administration in August 2019.”
Dr. Dylan Luyten is the director of emergency medicine at Swedish Medical Center in Englewood. Dr. Luyten also serves as an EMS medical director, providing guidance for the 911 system. He works directly with first responders and is an expert on the use of sedatives in emergency situations. He spoke to Denver7 at length this week about the pros and cons of ketamine as compared to other sedatives. Below you'll find our conversation with Luyten, which has been edited for length and clarity.
Q: What is ketamine, and how is it used?
A: Ketamine is one of the most important drugs, honestly, in emergency medicine, trauma and critical care. And it’s a complicated medicine. It turns 50 this year. We’ve been using it for a very long time. And I don’t think it’s ever been more important than it is now.
It’s complicated. It’s a medicine that is useful as a sedative. It’s also useful as a pain medication. And it has complicated effects. It’s an anti-inflammatory medicine, and now we understand it’s a very powerful anti-depressant medicine. So it’s used in lots of different arenas within health care.
Q: How is ketamine used to treat pain?
A: Ketamine has complicated effects. Depending on the dose given, different effects will predominate. At lower doses, ketamine is a very effective pain reliever. We like it because, unlike other pain relievers, it has minimal effect on patient’s breathing. It can safely be administered to patients who are critically ill, like a trauma patient with multiple broken bones, or a child who needs both pain relief and sedation so that a fracture can be set safely in the emergency department.
Were you to use an opioid, for example, to achieve the level of pain control that you need, you might require very, very high doses of an opioid, which could begin to create problems with the patient’s breathing. So we like ketamine for that reason.
Parents in your audience might have had a child in the emergency department with a complicated wound that needed suture repair, or a broken bone. We use ketamine a lot in children because it is such a safe medicine, and because it provides such reliable, predictable pain relief, as well as sedation. It has a lot of use in pediatrics. I’d say we use it every day in the emergency department.
Q: How is ketamine used as a sedative?
A: Ketamine is different from some sedatives. It provides dissociation. It’s a sedative-dissociative-amnestic-analgesic, which is a mouthful. Dissociation is the characteristic of ketamine that it’s probably most known for. A dissociative state is one where, you would describe it as, “the lights are on, but nobody’s home.”
If you administer a lot of opioid, like morphine or fentanyl, or a lot of a benzodiazepine, like Valium or Xanax, patients will just fall asleep. In that state, their breathing is disordered, and they may not be able to protect their airway and their breathing.
By comparison, with ketamine, the patient is actually awake, they just aren’t interacting with the world. "The lights are on, but nobody’s home.” Their eyes will be open, and they are breathing spontaneously, but you can startle them or do a manipulative fracture, and they really don’t pay attention to it. It’s that state of dissociation that is unique for ketamine.
Q: You are an EMS director. How do first responders use ketamine?
A: In EMS, ketamine is relatively new. The first reports of ketamine use in EMS, emergency medical services, are around 2005. It’s only spilled over in the last 15 years.
A lot of the experience with ketamine has been gained in the battlefield. It is extremely popular and widely used in the Army and the Marines and in battlefield scenarios. It’s favored there because it is so reliable, so easily given, has such a rapid onset, and has such a good safety profile, in terms of its effect on breathing and blood pressure, which are minimal relative to traditional pain relievers and sedatives like Valium and morphine.
Colorado EMS only uses ketamine for two purposes: One is for pain control. The other is sedation in the case of severely agitated and combative patients.
The pain doses are very low dose. We favor that for people whom the use of an opioid may be ill-advised, like someone who is habituated to opioids. Or in patients for whom an opioid is relatively dangerous. Somebody who has high risk of compromised breathing or airway. Somebody who’s perhaps very obese, or very frail, or somebody who’s had a lot of blood loss, so their risk of low blood pressure is very high. Ketamine is really preferable in those scenarios.
In the context of our current national opioid epidemic, we’re very interested in finding alternatives to opioids. Ketamine’s become increasingly popular in that context.
In terms of its use for highly agitated and combative patients, ketamine is highly preferable compared to the alternatives. Traditionally, when EMS would encounter folks who are extremely agitated or combative – often in the case of cocaine, methamphetamine, alcohol or other stimulant use – EMS would traditionally use a medicine like Valium, which is very slow in onset and has a lot of respiratory depression, and is highly unpredictable in its effect. Or, they’d use a traditional anti-psychotic medication like Haldol, which similarly has a very slow onset and is somewhat unpredictable.
The problem is that when you look at the most severely agitated, combative patients, they are at high risk of death. The cause of death is complicated, but relates to the buildup of acid in their blood from intense struggle. Picture an athlete who has been running wind sprints on a hot day. They are hyperthermic, overheated, dehydrated, have a buildup of lactic acid in their system. That’s similar to someone who has overdosed on meth or cocaine. Their heart is extremely vulnerable to that combination of lactic acid and adrenaline, and it often results in a dangerous heart arrhythmia.
Every minute that EMS or law enforcement are struggling to restrain or contain someone in that state puts that person at very high risk of a lethal cardiac arrhythmia, or sudden loss of ability to breathe. If you use a medicine with 20 minute time of onset, that’s 20 minutes of the patient struggling and building up lactic acid.
When we look at clinical studies and research on the use of ketamine in this scenario, we find that on average, ketamine sedates the patients in this condition in around five minutes. That’s compared to something like Haldol or Valium, which could take twenty minutes or longer. For that reason, ketamine is favored for extremely agitated patients.
Ketamine is only available for use in Colorado under a waiver process. For me, with my fire departments and EMS agencies, I’ve applied for a waiver with the state department of public health, and that waiver is highly managed. This isn’t given willy-nilly. It’s given under the most extreme circumstances. My fire departments might give ketamine for extreme agitation two or three times a year. For pain, we might use it a few times a month.
Q: Can a patient have a cardiac arrhythmia, even if they are given ketamine?
A: Absolutely. Ketamine is not an anti-arrhythmia medication. It doesn’t prevent arrhythmias, but what it does do is allow for rapid sedation so that the patient is no longer struggling, so they can be safely cared for from a medical standpoint.
These highly agitated patients are the most critically ill patients we care for. The analogy is to a patient who’s suffered cardiac arrest. That’s the level of critical care that is required.
You can rapidly sedate somebody with ketamine, but that’s where your job begins. At that point, that patient is a critically ill patient, and they need cardiac monitoring and oxygen. They may sometimes need a breathing tube. They need to be cooled. They need to have their lactic acid cleared with IV hydration. All of these measures are necessary.
Ketamine itself doesn’t prevent the arrhythmia. What it does is allow you to safely care for the patient, and provide the critical care they need.
Q: What are some other uses for ketamine?
A: It’s worth noting that ketamine is being used now as an anti-depressant. There’s a growing body of evidence that shows its efficacy for severe refractory depression. Ketamine infusions are part of that care. It’s not routine care, but it is widely accepted as useful.
Ketamine has anti-inflammatory properties. There is interest in ketamine’s use in critical care for those purposes. In the context of trauma, critical care, and emergency medicine, it’s primarily used as a sedative and as a pain reliever. And it’s used every day. It’s one of the safest medicines we have.
My children, when they were younger and in the ER with a broken bone or burn or facial laceration, have had ketamine. It’s really a cornerstone medicine in the emergency department.
Q: Is there anything else people should know about ketamine?
A: Any sedating medicine has abuse potential, and ketamine has abuse potential. It’s clear that ketamine has a niche abuse potential because of its dissociative state. It has some overlap with hallucinogens and club drugs, slightly different from alcohol or Xanax or morphine or heroin. It has some common properties, but it’s different.
It is easily scapegoated because it has that reputation of horse tranquilizer. It sounds, just the very mention of it, sounds perjorative or suggests a misuse. As an EMS physician, we feel strongly that ketamine is the safest option for these most severely agitated and combative patients.
I remember working at a free-standing ER. I had a patient come in who was an actual MMA fighter. A huge individual, body builder. He had been working on his gutters and fallen off his second story roof and hit his head on the sidewalk.
His girlfriend managed to get him into the ER, but he was out of control. We immediately called 911 for help, because he was so menacing. And we immediately administered ketamine through his jeans. By the time police arrived in five minutes, he was just lying on his back and staring at the ceiling. We were able to care for him. He had broken bones and a bad head injury. He meant us no ill will – he was just out of his head.
Ketamine is the safest drug. If I had to use Haldol or Valium or something to achieve the same result, it could have taken half an hour. All that time we are struggling with him. It is very dangerous for all of us.
Have you ever seen “Do The Right Thing”? Radio Raheem, tragically, at the end is in this chokehold with police. Historically, these extended physical struggles with law enforcement and fire... obviously, that’s a malignant scenario that’s portrayed in the movie, but those kinds of physical struggles are not uncommon with law enforcement. Fire is often there because it’s a 911 call. The ability to rapidly sedate someone prevents the extended physical restraint that causes broken bones, choking and death.
There’s this instinct, when you’re struggling with somebody, your own safety feels at risk and you’re frightened. Your adrenaline is up over an encounter like this with someone who is dangerous. There’s an instinct, when you achieve some level of sedation, to step back and say, “Finally, we have this person calm.” But that’s the point where EMS’ job begins. Patients are critically ill at that point. And that’s when we get in trouble – when we ignore the critical care part that starts when we administer ketamine.
I'm hearing anesthesiologists and people who, frankly, don't have experience with ketamine pre-hospital or emergency scenario, commenting on this. You'll hear an anesthesiologist say, "Well, this is a general anesthetic." And that's true. But so is alcohol. You give someone enough alcohol, it's general anesthesia. You give someone enough fentanyl, it's general anesthesia.
I don't think any EMS physician would argue that very high-dose ketamine achieves near-general anesthesia levels of sedation. Nobody argues with that. The point is, these are people who are trained to deal with these situations.
For someone to comment who is in an OR, giving doses of a sedative pain reliever to a fasted elective surgery patient while Taylor Swift is playing on their Sonos in the background, is just wildly out of the context of what is happening with these emergency situations.