Wednesday, July 01, 2020
Alex Papp MD
In the summer of 2019, a young man, Elijah McClain, died after being arrested by the police. During the arrest he became agitated and EMTs were called to the scene. The EMTs injected Elijah with ketamine to “sedate” him. He died at the hospital several days later.
Ketamine is NOT a sedative.
Sedatives trigger a set of receptors called GABA receptors. When GABA receptors are activated, they exert a general sedating effect on the central nervous system. Drugs that activate the GABA system include well known anti-anxiety agents (e.g., Valium or Xanax), sleeping pills (e.g., Ambien or Lunesta), muscle relaxants (e.g., Baclofen or Soma), and even recreational drugs like alcohol.
Ketamine has a different effect on the GABA system. Via an indirect route, it inhibits it, instead of activating it. This is part of a very complex web of actions on various systems in the brain which produces the ketamine effect as it is observed clinically.
The neurological effect of ketamine is not sedation but a state called “dissociative anesthesia”. Persons anesthetized by ketamine may look sedated, may even act sedated, but they are not sedated. Anesthesia simply means “no-feeling”. It does not mean sedation.
“No-feeling” can be achieved by various means. Lidocaine, for example, allows a doctor to quickly remove something from the patient’s skin, without “sedating” them. The patient is anesthetized, not sedated. Ketamine achieves anesthesia by “dissociation”, which means decoupling people’s conscious awareness from their bodies. It is the inhibition of the GABA system that changes certain balances in the brain so that this decoupling can take place.
Ketamine-induced anesthesia allows surgical procedures to takes place without pain, allows burn victims to receive wound care without suffering, or accident victims to receive pain relief on the scene, administered by EMTs. That is what it’s for.
When a person is under the influence of ketamine, other changes occur, besides dissociation. These most often involve an increase in blood pressure and heart rate. Scary images imagined in a dissociated state can cause panic attacks. These can be easily managed in a supportive environment, such as a hospital, or an ambulance vehicle.
But a difficult police arrest is NOT a supportive environment. When someone is agitated (and likely scared), such as Elijah, the heart is pounding and blood pressure rises. It is also possible that frightening hallucinations further stressed his heart by flooding his blood stream with more adrenalin.
Elijah received 500 mg ketamine intramuscularly in an agitated state. It is easy to imagine how such a high dose of ketamine could have pushed his heart rate and blood pressure into such heights that it eventually killed him.
In summary, although ketamine is sometimes given by EMTs as an anesthetic when treating victims of accidents, it should never be given in an attempt to sedate an agitated person. Its use to “sedate” detainees in police arrests must end. One can only hope that this will serve as a wake-up call for those responsible for the training of emergency personnel and police departments about the dangers of the improper use of ketamine.
