A National Analysis on Statewide Prehospital Adult Behavioral Sedation Protocols with a Focus on Trends in Ketamine Administration.
The Journal of emergency medicine · 2025-08-21 · Observational study
Abstract
BACKGROUND: Prehospital clinicians are trained to treat medical emergencies and operate under treatment protocols that may be statewide, regional, or agency-specific. Prehospital treatment of behavioral health emergencies (BHE), especially with ketamine, has gained public attention over the past decade. OBJECTIVES: This study describes the current characteristics of prehospital statewide adult BHE protocols used across the United States (US) with a focus on trends in ketamine administration. METHODS: We conducted a cross-sectional review of mandatory and model statewide emergency medical service protocols and identified adult BHE protocols for inclusion. State protocols with a median publication year of 2023 were examined to evaluate protocol characteristics and the use of benzodiazepines, antipsychotics, and ketamine. A subset of current protocols was compared to archived versions to assess changes in ketamine use. RESULTS: Thirty-two states representing 47% of the US population had statewide BHE protocols. Most protocols included verbal de-escalation, physical restraint, and postrestraint monitoring requirements. Less commonly found were objective scoring systems for agitation, process assurance indicators, and alternative destinations. The most frequently used medications included midazolam (n = 29; 91%), ketamine (n = 29; 91%), and haloperidol (n = 21; 66%). A temporal assessment of ketamine in BHE protocols revealed increasing adoption accompanied by expanded safety precautions. CONCLUSION: This cross-sectional study of 32 US prehospital BHE protocols found relative inter-regional agreement except for a few notable differences, such as medication choice between protocols. During the study period, ketamine use in BHE protocols became more common with a shift toward enhanced safety precautions and uniform dosage guidelines.
Abstract © the authors or publisher, via PubMed. Reuse and removal
Tags
Anaesthetics · Antipsychotics · Ketamine · Midazolam · Sedatives & anxiolytics
Related articles
- Exploring Current Emergency Medical Services Approaches to Manage Agitated Older Adult Patients: An Analysis of Statewide Protocols. (J Am Geriatr Soc, 2026)
- Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine. (Prehosp Disaster Med, 2016)
- Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. (Am J Emerg Med, 2022)
- Prehospital management of acute behavioural disturbance: managing severe agitation in the prehospital setting - a systematic literature review. (Emerg Med J, 2026)
- Comparative Safety of Medications for Severe Agitation: A Geriatric Emergency Department Guidelines 2.0 Systematic Review. (J Am Geriatr Soc, 2025)
- Review, clinical update, and practice guidelines for excited delirium syndrome. (J Spec Oper Med, 2015)