June 30, 2025

Ketamine is a powerful medication with multiple uses in our protocol, though it is relatively safe. Due to untoward events in our EMS world, including a death in Columbine, CO, and documented apnea in Columbus, OH, the medical directors came together with our leadership and have a program that demands a 100% review of any dose of ketamine over the 10 mg IV pain dose. We are proud to say that with the fine work of our prehospital providers and this oversight led by Jonathan Cameron, we have not had any critical events with the use of ketamine; we’ve had areas of improvement with post-medication monitoring. The number one missed monitoring event is failure to check glucose after sedation. Knowing that a glucose check is mandatory for any of our multitude of altered mental status patients, it goes without saying that any patient requiring sedation needs to have their glucose checked. 

The following is a real case that I reviewed last week. A 29-year-old female was combative and violent at her home. EM0S was unable to provide care and did not want to disassociate this patient, so they administered Ativan (RSI Unit). This didn’t help, especially with this medication taking up to 30 minutes for an IM dose to work. With the situation still dangerous, they administered 250 mg of ketamine. After five minutes, she was still extremely violent and required a second dose of ketamine 250 mg IM. She became sedated but still agitated. Then, they arrived at the Samaritan ED. The ED team monitored her glucose immediately, and her glucose was 50. They administered glucose immediately, and the patient did well. I spoke to the crew, and they had left their glucometer at the residence. Here, there was no harm done as the glucose was at least over 40, but that was just fortunate. I have also had medics tell me, “The patient wasn’t diabetic.” Ketamine can induce both increased and decreased glucose levels. 

If your team is using ketamine, remember what we learned in paramedic class: right patient, right drug, right dose, right time, and right route. We also require two providers present for all medication use, including IVF. Reliable care requires closed-loop communication, and our “speak up” culture requires that we all listen to each other.

Some side effects to be aware of: 

• Allergic reactions (rare) 

• Hallucinations 

• Laryngospasm (Usually in peds and very self-limited and rare) 

• Loss of contact with reality 

• Palpitations (usually self-limited) 

• Salivation (especially with IV chemical-assisted ventilation) 

• Transient hypertension 

• Transient hypotension (not as common as hypertension) 

Post ketamine over the 10 mg pain dose required by protocol: 

• Blood glucose 

• Cardiac monitoring 

• Frequent vitals 

• Pulse ox 

• Capnography 

• ABCs

Ketamine is a very safe medication, and we all use it for pain, intubation, and emergency sedation. Careful post-medication monitoring will allow us to keep this powerful medication aid in our protocol for years to come. 

Sincerely,

Don Spaner, MD