Episode 2 - Ketamine & The Drug Box

Ketamine & The Drug Box


March 2023


Scott Wildenheim

Caleb Ferroni

Ray Pace


Donald Spaner, MD ( and dog Hank )

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TXA and PDE Protocol Update

Since this episode was taped, there have been 2 protocol updates that were not discussed. 

When this was taped, TXA was given as 1000mg (1 gram) mixed in 100ml over 10min. Now that has changed to 2000mg (2 grams) mixed in 100ml over 10 mins. It can also be hand pushed, but it still needs to be over 10 mins. 

In addition, the protocol team has since removed any timing requirements on the re-dosing of push dose epinephrine (PDE). Previously it was dosed every 2-5 mins. Now it can be re-dosed as soon as you know you need more. Likewise, if the initial dose of 10mcg has not produced a satisfactory BP or HR, up to 50mcg / dose may be administered to stabilize your patient. 

Episode Videos

Ketamine - Introduction Part 1

Ketamine - A Practical Review,      Part 2 

Ketamine and The Drug Box, Part 3

Ketamine & The Drug Box Recap, Part 4

Episode Audio

Show Notes

In this episode the guys are joined by Don Spaner, MD the CMO of the University Hospitals EMS Institute. The discuss all aspects of ketamine use, protocols, pitfalls, and public opinion. Part 3 of the series finds the guys discussing TXA, Push Dose Epinephrine, and Certadose Pediatric medication tool. 


UH Mindset


The Medication


Indications – Protocol


Pain use

Good for patients who are working a narcotics recovery program – ketamine non-narcotic but has significant opiate caliber analgesia. These patients still deserve Pain management, while not risking their recovery

Good for patient well acclimated to narcotics and now desensitized.  Stimulates NMDA receptors rather than MU like narcotics. Works by different mechanism,  may give relief when narcotics may have failed.  Sickle cell cases are a good example of this.

Good for shocked trauma patients. Ketamine has stimulant properties that increases HR and BP. Its likely safer in these cases as the HR is compensatory in the shock state. Blunting Pain in this case may unintentionally dump BP by reducing the HR which is due to the pain. Giving ketamine (after other resuscitation measures are underway) may prevent this unintended BP drop by directly increasing the BP and HR while simultaneously addressing pain.





Dissociative dose > 1-2 mg/kg

Want to “come heavy” with this dose to assure appropriately disassociated, larger boluses than when compared to pain dosing.

Usually 100 mg, attempt procedure, repeat 100 mg in 2-3 mins if needed. If patient unresponsive to 200, add benzo and or analgesic (fentanyl) these patients may have a tolerance to PCP-like substances and may need combination therapy to induce.

Be prepared to suction, these larger doses often create excessive salivation

Patient will still be breathing (unless some untoward polypharmacy reaction, or other unanticipated situation)

Will have to time tube delivery of ETT with vocal cords.

Drug assisted airway protocol not limited to just delivery of ETT, can be used with extraglottic airways also


Major tranquilization dose - Violence


Operational Pharmacology / Equipment Use

Carpuject Use


Alternately the luer lock end can be removed from the carpuject cartridge and the medication drawn with another needle and syringe from the rubber stopper. DO NOT inject any air, this will blow the stopper out of the rear of the carpuject. Drawing medication will pull the stopper down as you withdraw medication.


IV sets

Different ports on IV tubing require different ways of adapting syringes or other IV lines to them

3 Basic types:


Push Dose Epinephrine (PDE)

Making PDE the locally sanctioned way

Place 1 mg (1000 mcg) of 1mg / ml (1:1000) concentration – epi vial – into a 100 ml bag of D5W. Agitate. Withdraw from same injection port on D5W bag and administer – below.

Why this way is sanctioned locally;

D5W is the most often supplied mixing base as all medications that EMS needs to mix are “happy” in D5W. Some other medications are less properly mixed in saline. So D5W is supplied as the “standard” mixing base in our boxes. Epi is perfectly happy in epinephrine if that is all you have.

Administration – for hypotension and / or bradycardia

Push 1ml of the 10 mcg / ml concentration and reassess

Epinephrine is metabolized fast. In the time the machine re-assesses if the resultant values are low, administer more PDE. If the BP does not “move” much ex. You start with a BP of 60/40 (Map 47) and the first 10 mcg of epi move the BP only to 66/43 (Map 51) then you can increase subsequent doses to push it further along. Subsequent doses are not entirely additive to the preceding dose, because its metabolized quickly, in some regards you are basically starting over every push. You might consider 20 or 30 mcg push on the next administration given the case presented. You may give up to 50 mcg / dose as needed to stabilize your patient.  

 Whereas the introduction of PDE to protocol was to encourage pressor use in lieu of pressor drips, drips are not disallowed. In fact, the concentration mixed for PDE is actually very functional for converting to a drip once stabilized with PDE. If a bag of PDE is mixed as discussed above (10 mcg / ml) and spiked with a 10 drop set that means that every 10 drops that fall out of the chamber = 1 ml. 1 ml = 10 mcg’s. Or said another way, each drop = 1mcg. This makes figuring out how many drips / min are needed really easy if you started with PDE. Lets say you gave the patient 70 mcg over about 5 mins to stabilize them, the patient averaged about 14 mcg (70 / 5) per min. Once your bag is spiked, you know the patent “likes” about 14 mcg / min, all you need to do is count out 14 drops (14 mcg) every min with a 10 drop set. This only works this smoothly with a 10 drop set.


In pediatrics PDE is given for shock at 1 mcg / kg up to 10 kg. This means that every 22 pound (10 kg) or greater kiddo can have full adult doses. This is red boxed (online medical control required) in UH and surrounding systems. Most peds will respond to fluid boluses thus negating these medications.


Tranexamic Acid (TXA)


Tranexamic acid (TXA) indicated in hypotensive and tachycardic (systolic less than 90 heart rate greater than 120) after uncontrolled hemorrhage. In other words this is for shocked trauma patients. This must be given within 60 mins of the injury to be effective.

There has also been added an epistaxis indication in the 2023 protocol. For nose bleeds that are refractory to standard BLS care a TXA soaked gauze product can be used for packing. In this case, the provider chooses which gauze product to use, and soaks it in TXA. Once soaked, the affected nare(s) are cleaned out by blowing or suction of the nose then packed with the soaked TXA gauze.



TXA is a reversable antifibrinolytic that inhibits the conversion of plasminogen to plasmin, thus keeping clots intact. TXA does not “MAKE” clots. Giving such a drug to a person would yield an immediate death from a concurrent MI, PE, and Stroke. This only preserves existing clots to prevent additional or rebleeding and allow more time and better survival for surgical intervention.



TXA is supplied as a 1000mg (1 gram) vial. The current protocol calls for 2 grams ( 2 vials) of TXA mixed in a 100 ml bag of D5W and given over 10 mins or hand pushed over 10 mins. Kids are given 15 mg / kg mixed into a 100 ml bag and given over 10 mins. This is red boxed (online medical control required) in UH and surrounding systems.


Naloxone (Narcan)

Narcan is given to restore respirations in known or suspected opiate overdoses. This should be the only indication. There have been cases of patients who are altered, but breathing, or have just admitted to use of opiates but are awake that have received Narcan. These patients may be dosed with an opiate, but are not overdosed as suggested by the fact that they are breathing.

The overarching rule with these cases is the “resuscitate then antidote” mindset. If a BVM is not required, then neither is Narcan. Begin BLS ventilation, support circulation as necessary, then add the antidote.

The overdosed patient is both hypercarbic and hypoxic from not breathing adequately or at all. Breathing for this patient, with supplemental oxygen will often result in the them waking simply by correcting the hypoventilation. These patients need Narcan to combat the opiates and maintain their breathing.

It is not appropriate to get on scene, administer the Narcan, and hope it restores their breathing without ventilatory intervention from EMS. Understand intranasal (IN) Narcan requires time to work, and absorption rates vary with each patient. Likewise IN or IV use of Narcan requires perfusion to work quickly. Someone in hemodynamic collapse may not “pick up” the drug quickly. IV is preferred when available.


Olanzapine (Zyprexa)

Zyprexa is an newer generation anti-psychotic medication. It could in some respects be thought of as a oral haloperidol (Haldol) with fewer side effects. They have similar indications and effects. Zyprexa in EMS is supplied as a ODT (orally disintegrating tablet) 10 mg tablet. Being a orally delivered medication, the patient has to be somewhat cooperative and willing to use the medication.


Indications – Protocol

Zyprexa is indicated for acute agitation in a patient with psychosis. This is not for all episodes of agitation. So, this would not be indicated in panic or anxiety attacks, or undifferentiated agitation cases. This is for bipolar or schizophrenic cases that are agitated and may be hearing voices or seeing things.



In the patient who is amenable to the use of the medication, a single 10 mg tablet is given orally. This, like most other ODT tablets should be allowed to melt in the mouth then swallowed down. In practice most providers give this SL, as most patient seem to understand “let this melt under your tongue”. Onset is usually within 10 mins. This is not given with concurrent benzodiazepines by EMS.



Zyprexa is supplied in ODT blister pack that looks very similar to our more frequently used ODT medication, ondansetron (Zofran). The trade name of both of these drugs start with “Z” and both generic names also start with “O”. The combination of look alike and sound alike make these medications a prime situation for a medication administration error. Be sure to double or triple check when using either of these agents. UH packages and labels the Zyprexa to assure that it stands out as different from the Zofran.


UH EMS Drug Box Program

The University Hospital drug box exchange program supplies pharmacy stocked and maintained drug boxes for the EMS system. The drug box and its contents are tracked by an RFID tag system called Kitcheck. These are the little tags added to each medication in the drug box. This allows the boxes to be quickly scanned for content and expiration by the pharmacy.

Drug boxes are exchanged at your medical control hospital when the are expired or exhausted. This may be done in the ED or in the Pharmacy depending on the hospital. The box is exchanged for another fresh box when needed.

The boxes are sealed with green seals from the pharmacy. Inside there are red and yellow seals. The yellow seals are used when something is used from the box, but the box is still serviceable. These would be cases where there are still enough medication of a particular class or category to fulfill all protocols relevant to that medication. Red seals are used to flag a box is not serviceable by the previously noted cases or any controlled substance has been used.

There is a medication tracking form that is included in each box and is required to be filled out and sent back with the box. It is good practice to fill out the form and take a picture for attachment to your ePCR with the call.

The Protocols

Certadose Resources

UH Certadose Protocol

Certadose Training Video

Certadose Instructions.pdf

Certadose Instructions

Episode Shorts

Ketamine Part 1

Acute Psychosis


Ketamine 250 mg IM

Ketamine Part 2

Naloxone (Narcan)

Olanzapine (Zyprexa)

Tunnel Vision

Advanced EMT

The Basics

Push Dose Epi Part 1

Push Dose Epi Part 2

Push Dose Epi Part 3

Making Push Dose Epi

Needless Tubing

Luer Lock Tubing

TXA Does NOT Make Clots

UH EMS Drug Box

Controlled Substances & The Drug Box

Pediatric Dosing Index

Ketamine Live

From The Episode

Scott demonstrates proper technique to break a carpuject

Ray critiques Calebs Band-Aid application technique

Dr Spaner discusses something, likely important

Caleb reflects on his favorite medications of all time