Monday, July 2, 2018

Sedation of Patients experiencing Excited Delirium in the Prehospital Environment

Concerns have been expressed recently regarding the administration of medications – including ketamine – by emergency medical services (EMS) providers to sedate delirious and often violent patients in the prehospital environment.

Safety is the primary driver for the use of sedative or calming medications.  Patients who are violent due to psychiatric disorders and/or substance use often lose the ability to respond to verbal calming techniques.  As a result, they present a significant health and safety risk to themselves and to those around them.  Death may result from severe metabolic abnormalities that are worsened by uncontrolled agitation.  

Emergency medical services (EMS) physician medical directors across the United States implement protocols that paramedics use to care for their patients. These may include guidelines for the management of violent patient situations that address stepwise implementation of verbal calming and de-escalation techniques, followed by physical containment and/or sedation.  The goal is to safeguard the patients, while also reducing the risk of violence directed against EMS and public safety workers.

Coordination with law enforcement is critical to the safe management of violent patients. This partnership between EMS and law enforcement is intentional and is the result of a considered effort to decrease the risk of in-custody death. Appropriate uses of physical containment and restraints as well as sedation with calming agents are critical tools for the safety of both the patients and the responders who are called to care for them. Law enforcement officers are typically the most highly trained individuals to safely physically subdue violent people and are most qualified for initial management. The use of medications is, however, solely the decision and responsibility of EMS. Allowing delirious or agitated patients to continue to struggle against physical restraints is medically dangerous, ethically unacceptable, and increases the risk of injury or death. Almost all individuals in this condition require monitoring and transport by EMS to an emergency department for further evaluation. They are clearly medical patients until their condition is diagnosed, treated, and stabilized.

A variety of medications are currently considered appropriate options for sedation in this setting. These medications are widely used throughout the country and are included in the National Model EMS Clinical Guidelines. Ketamine has gained recent favor in many EMS systems due to its safety profile in patients with violence resulting from psychiatric and/or drug-related influences.  Numerous EMS systems have extensive experience that supports the ability of EMS to safely administer ketamine in this difficult patient population.

We, the undersigned EMS Medical Directors, strongly support the use of medications to calm delirious and/or violent patients who are a danger to themselves or others.  We endorse the use of appropriate sedative medications – including ketamine – when administered by well-trained paramedics who are functioning under carefully designed medical care protocols. Patients and EMS workers are safer as a result.


Peter Antevy MD - Broward County FL, Palm Beach County FL
Glenn Asaeda, MD – New York City
Sabina Braithwaite, MD - Saint Louis
E. Stein Bronsky, MD - Colorado Springs
Charles Burnell, MD - Acadian Ambulance Service, Inc.
Jose G Cabanas, MD – Raleigh
Elizabeth Char MD - Hawaii
Brian Clemency DO - Western New York
M. Riccardo Colella, DO – Milwaukee
Thomas E. Collins MD – Cleveland
Christopher B. Colwell, MD – San Francisco
Robert B Dunne MD - Detroit 
Craig Ellis, MD – New Zealand
Mark E. Escott, MD – Austin
David French, MD – Charleston
Ray Fowler, MD – Dallas
John M Gallagher, MD - Wichita
John V. Gallagher, MD - Phoenix
Marc Gautreau, MD – San Jose
William S. Gilmore, MD – St Louis
Jeffrey M. Goodloe, MD, Oklahoma City & Tulsa
Drew Harrell, MD - Albuquerque
Joe Holley, MD – Memphis
Jon Jui, MD - Portland
Emily Kidd, MD - Acadian Ambulance Service, Inc.
Michael Levy MD - Anchorage
Donald Locasto, MD – Cincinnati
Chuck Mason, MD – Little Rock
Craig Manifold, DO - South Texas
Kevin McVaney, MD - Denver
Crawford Mechem, MD – Philadelphia
David A. Miramontes MD - San Antonio
Dan O’Donnell, MD - Indianapolis
Stefan Poloczek MD, Berlin
Neal J. Richmond, MD - Fort Worth/Tarrant County
Ronald Roth, MD – Pittsburgh
Michael R. Sayre, MD – Seattle
Kenneth A Scheppke, MD – Palm Beach County
David E. Slattery, MD - Las Vegas
Corey Slovis, MD – Nashville
Terence D Valenzuela, MD – Tucson
Veer Vithalani, MD - Fort Worth
Arthur H. Yancey II, MD – Atlanta
Scott Youngquist, MD Salt Lake City