There are 2 ways to sedate the agitated or delirious patient. The right way or the other way.

Why risk yourself or your partner.

It is so hard to get some people to understand or be on-board with specific medications.  Ketamine is one of them.  Ketamine is one of the safest and most protective medications out there.  Many places use a 4-5mg/kg IM injection.  Imagine:  You are called to a combative patient.  He is swinging at the cops and they take him down.  While on the ground, you stroll up stick 250-500mg of Ketamine into their thigh and push it.  Then everyone gets up and moves back from the patient.  The patient has roughly 30 sec to maybe 5 minutes at most before they are flying in the clouds with their airway intact, and very little impact on ICP, BP, or Cardiac Output.  

I started like so many of you, IM injection of Ativan or Versed.  Oh man, dealing with a combative patient for more than 30 minutes is not fun.  I wish I had been introduced to Ketamine on day one.  I have literally taken a patient 55 miles and gave 2 doses of 2mg Ativan hoping that they wouldn't break the restraints.  The worst part is once I arrived at the facility all 4mg of ativan had taken ahold and my patient was a big pile of goo with severe respiratory depression.  I was chewed out by the doc and my medical director.  I had to state that I couldn't attempt an IV as the patient was fighting me the whole time, and I couldn't get PD to hold them down for me to start an IV.  Now that I'm much, much older and have experienced so many more calls.  I know better...

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The Ketamine vs B52 Debate

How many of you have watched a hospital deal with an agitated aggressive patient with a B52? For those who don't know what a B52 is; It combination, (not mixed) of Benadryl 50mg, Ativan 2mg, Haldol 5mg, usually given IM. Then often there is the wait. I have personally encountered a combative meth/bath salt patient who had no reaction to the first B52 and had mild sedation after the 2nd dose. The doctor was amazed, she had never seen anybody stay awake for over an hour after a B52. After consulting with another physician, it was agreed that a different approach should be taken. They walked in with 400mg of Ketamine, stuck the patient in the leg and within 3 minutes he was out. They followed up with Versed and a Propofol drip. The patient was placed on a ventilator and moved to critical observation. The magic of this scene proved that tried and true ways of controlling patients may not always work. The following is taken from www.drugs.com/pro/ketamine-injection.html

The anesthetic state produced by ketamine hydrochloride has been termed "dissociative anesthesia" in that it appears to selectively interrupt association pathways of the brain before producing somatesthetic sensory blockade. It may selectively depress the thalamoneocortical system before significantly obtunding the more ancient cerebral centers and pathways (reticular-activating and limbic systems)."