ED Treatment of Suicidal Patients With Ketamine Infusion

Suicide has risen to the 2nd leading cause of death in Americans aged 10 to 34, and is
the10th leading cause of death overall. Globally, the World Health Organization estimates one
person dies of suicide every 40 seconds. Despite its lethality, no recognized acute
treatments for suicidality exist. Recently, ketamine, an N-methyl-D-aspartate (NMDA) receptor
agonist, has been shown to rapidly reduce suicidality in small studies in psychiatric
settings. However, most patients with acute suicidal thoughts are treated initially in
Emergency Departments (EDs). Delays in treatment have both short and long term impacts on
recovery as patients spend longer time frames in an actively suicidal state.

Identifying a rapid and effective treatment for suicidal ideation that can be administered in
the ED would have a profound impact on the emergent management of patients with suicidal
thoughts. Ketamine is an FDA approved medication that is commonly used in EDs for multiple
indications. EDs have the familiarity, facilities and personnel to safely administer IV
ketamine.

Ketamine is regularly used in EDs in high doses for procedural sedation in adults and
children. It is also used in high doses as a sedative for acutely agitated patients. In
low-doses ketamine is frequently used for its analgesic properties and is considered safe.

Ketamine has also been safely used in the pre-hospital setting. In a recent joint policy
statement of the American College of Emergency Physicians recommended the use of low-dose
ketamine for pain in control with a safety profile comparable to other intravenous analgesia
such as morphine.

Use of Ketamine to rapidly reduce suicidality may facilitate a safe and faster transition of
acutely suicidal patients to outpatient treatment. Such treatment potentially shortens these
patients' ED and hospital lengths of stay.

Inclusion Criteria:

- Age ≥ 18 years

- Chief complaint of suicidal thoughts with a MADRS-SI score > 3

- Major depressive episode with MADRS > 19 (moderate to severe)

Exclusion Criteria:

- Pregnancy

- Psychosis

- Acute intoxication with alcohol or illicit drugs

- Acute withdrawal from alcohol or illicit drugs

- Adults otherwise unable to consent

- Concurrent, active medical illness requiring medical hospitalization

- Inability to follow-up including no permanent address or valid telephone number

- Patients unable to attend outpatient follow-up (no medical insurance, refusal to
follow-up, no established care provider)

- Specific contraindication to the use of ketamine (concern for increased intracranial
or intraocular pressure, known allergy to ketamine)

- Greater than 12 hours from time of ED presentation

- Prisoners