Objective: Provision of Emotional Care to Individuals and their Support Systems suffering from agitation, and uncontrollable distress due to sudden traumatic impacts.
Core Method: Administration of Intramuscular ketamine at low dosages to provide a time-out from overwhelming obsessions and agitation in order to reconstitute with increased clarity and presence of mind-enabling rapid return to a level of functionality–and to reduce the depth of a future Post-Traumatic Stress Disorder and perhaps its incidence.
Concerns
- Avoidance of a ketamine induced confusional state.
- Presence of trained sitter(s)/therapists.
- Presence of family and/or other collateral support.
- Need for repetition of ketamine administration.
- Clinical/psychotherapy judgement always.
- Agitation under and after ketamine to be potentially treated as needed with midazolam.
Guidelines and Discussion
Ketamine at higher subanesthetic doses-depending on individual sensitivities–which are not known at onset-the probable range for greater effects being above 25mg IMhigher with its attendant loss of orientation-disorientationas psychedelic/hallucinatory potential may add to the difficulty of the emotional state. The immediate goal is a reduction of distress by a partial interruption of consciousness when consciousness is in a disrupted state by the impact of trauma. Higher dosages may be employed once there has been assessment of an individual’s sensitivity, but the goal as above remains the same.
Consideration of mgs/kg is not relevant at these low doses. What is relevant is individual sensitivity explored with administration of first dose determining subsequent doses for letting-go, ego-dissolution, and relaxation.
The word ‘relaxation’ is used herein to indicate a therapeutic response. This is not meant to indicate that the real concerns have abated. Rather that an agitated response has lessened, this allowing for a ‘sense of presence’ in the face of difficulty.
Single or repeated doses may be employed.
It is essential that the patient be accompanied and their experience expressed-and this may occur when in the ketamine experience and afterwards. Assessment for repeat ketamine administration needs to occur during this interval after the peak of ketamine’s influence-generally at 25 minutes or more.
Ketamine’s safety profile-and especially at low dosesdoes not have an impact on respiratory drive and will produce a transient elevation of blood pressure. Nausea may occur but is uncommon at low dose. Care in positioning is essential for minimizing the possibility of aspirationpreferably at a forty-five degree angle. With these low doses, there is no need for cardiorespiratory monitoring.
A brief intake particularly focused on medication, present and prior medical history is a necessity.
The question of voluntary and involuntary treatment needs to be answered situation by situation with collateral permission as possible and appropriate. This procedure would be difficult to employ in an emergency room setting where high levels of agitation require sedation to begin with and anesthetic dosage of ketamine may be administered.
Procedure
- Intake and history; prior use of alternative medicines; assessment of trauma and its impact on patient and social system. Brief Mental Status Exam-such as MiniMental.
- Discussion of ketamine’s use, side effects and administration–as much as possible. Informed Consent if possible, or from collateral.
- Decision to treat.
- First IM administration of 10-2Smg ketamine.
- Sitter/therapist present throughout. MD or prescriber present.
- Assessment of level of consciousness and agitation at 6-10 minutes allowing for full impact of ketamine.
- This leads to a decision to provide an amplifying dose during the initial ketamine period, or not: 10-25mg Reecognizing that dissociative effects will occur as dosage increases-continual assessment of discomfort, agitation, and degree of dissociation.
- As ketamine effect wanes, integration of the experience, assessment of agitation, and degree of relaxation is made by sitter/therapist with MD/prescriber awareness.
- A variable period for recovery occurs now.
- After assessment and with consent of patient (and collaterals), a second IM may be provided in similar dosage range-now with the experience of patient sensitivity to ketamine.
- This second experience and further experiences in what constitutes a session in this time frame are instituted as necessary to achieve goal. Total ketamine dose is recommended to be no more than 100mg administered in divided doses up to three in a session.
A) If agitation has continued to be difficult or has emerged during the actual ketamine treatment, consideration for use of midazolam 2.5mg is made.
B) If agitation has continued to be difficult and appears to be the result of an inadequate response to ketamine including the amplification of the first dose, and did not provide a sufficient degree of relaxation, a second dose may be provided in continuity with the first dose and its amplification–at the discretion of the prescriber and sitter/therapist. In other words, at about 15 minutes or so after initiation of the first dose. The cautionary is that this may increase dissociative effects and disorientation. - With relaxation and integration, a plan for continuation is made by the treatment team. This may include an additional session same day; next day; or during the week following the first session.
- Follow-up is a necessity.
- Awareness needs to include that additional trauma and/or traumatizing information may occur with further impact to the patient and/or support persons.
- If possible, an exit from the impacting situation needs to occur.
- Processing together by the treatment team is a necessity for collaboration, improvement in approach and technique, as well as prevention from burn-out.
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