Patch Requirement for Combative Patients

As the medical directive for Combative Patients currently stands there is no requirement for paramedics to patch to use Ketamine or Midazolam. However, there are specific indications outlined in the directive for the appropriate uses for each medication.

For administration of either Midazolam or Ketamine the patient must meet the indications of the directive, therefore exhibiting “combative or violent or agitated behavior that requires sedation for patient safety.”

Firstly, a quick review of some of the terms used in the medical directive:

Agitation: A condition of restlessness, irritability, nervousness, excessive motor activity, hostility, uncooperativeness, and/or excitement that can have multiple causes, including intoxication, withdrawal, psychosis, and many others. This includes a patient who is currently violent or aggressive, danger to self and others, attacking objects or people, or not redirectable and not responding to verbal de-escalation techniques.

Excited Delirium: Is becoming an outdated term but was previously associated in describing patients that were/are experiencing delirium and/or agitation immediately preceding collapse. The most appropriate term is hyperactive delirium with severe agitation.

Delirium: Currently, the DSM-5 lists the following five key characteristics-
Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness.
The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the day.

An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception).
The disturbances are not better explained by another preexisting, evolving, or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.
Severe Violent Psychosis: Thinking that has lost touch with reality, typically including delusions, hallucinations, and disordered cognition. An individual with untreated psychosis is more likely to act in an agitated and violent manner compared with the general population.

Secondly, for the management of these calls and these patients we always recommend attempting verbal de-escalation as first-line. Keeping the scene as calm as possible, using softer voices and language including non-threatening body language as much as possible. Making reasonable accommodations like allowing the patient to have a cigarette or making a phone call can also be helpful in avoiding escalation. This also often means extended scene times, possibly utilizing the partner that has the best rapport with the patient, and/or utilizing others on scene such as police, family or friends to help calm the patient. However, we do understand that these techniques do not always work, and chemical sedation then needs to be considered if the patient is a risk to themselves or others.

Therefore, Midazolam is recommended for patients experiencing significant agitation, combativeness, or violent behavior, but not considered to be experiencing a hyperactive delirium with severe agitation or severe violent psychosis. And Ketamine is recommended for patients experiencing a hyperactive delirium with severe agitation or severe violent psychosis. Think of ketamine when you are faced with a patient experiencing a very dangerous situation where they need rapid and reliable tranquilization to facilitate emergent control for assessment and treatment.

Management of these patients and calls can be very challenging, and further differential diagnoses are also very important to consider. If chemical sedation was needed and utilized, further investigation is required. Some reversible causes of combative, violent, or agitated behaviors can include hypoglycemia, hypoxia, hypovolemia, intoxication, psychiatric illness, etc. It is important to try and ascertain if any of these reversible causes can be reversed in these patients once the situation has been diffused and/or before the need for the use of Midazolam or Ketamine (if possible).

It is also important to note that a patch is required for any co-administration of Midazolam and Ketamine, including any instances of an emergence reaction from Ketamine. This emergence reaction can include further delirium while awakening from the Ketamine effects and Midazolam- is recommended- and can be helpful for these patients to help calm them.

One last thing to ensure is proper monitoring of the patients that receive Midazolam or Ketamine which includes EtCO2 monitoring along with other vital signs. Midazolam has significant sedation and respiratory depression effects. Ketamine, whilst not having as many respiratory implications, has significant sedation and amnesic effects. Once a patient has received one of these medications it is imperative that continuous monitoring occurs. Treat them as though you have just provided a general anesthetic, with close monitoring of airway and breathing.

In conclusion, a patch is not currently required to either utilize Midazolam or Ketamine, but there are specific situations where these medications are recommended. A great resource regarding these situations is available on MedicLEARN: [Course: Acute Behavioural Disturbances | MedicLEARN|https://mediclearn.rppeo.ca/course/view.php?id=689].