MontCo EMS LogoThis pilot was developed in cooperation with the Pennsylvania Department of Health, Bureau of EMS to test the effectivness of Ketamine when administered to a patient exhibiting signs and symptoms of excited (agitated) delirium. Excited delirium can be manifested by multiple mechanisms including acute or chronic illicit substance use, including the use of cocaine, methamphetamines, PCP, LSD, K2, and bath salts.

The administration of Ketamine protects first responders from being injured while providing safe care for these patients. The Montgomery County Medical Advisory Committee (MAC) supervises the 17 participating EMS agencies from across the Commonwealth. Patients suffering from excited delirium as well as the first responders in the Commonwealth of Pennsylvania benefit from the creation of a safe and proven excited delirium protocol to enabling paramedics to safely and effectively treat patients suffering from this toxidrome.  

The pilot program concludes on March 2, 2016. 

Ketamine Administration Chart

Pre-Hospital Pilot

Ketamine Administration - Montgomery County, PA

Please complete this form and submit to the Montgomery County Department of Public Safety office


Fax: 610-278-6254

Agency Name:
Date of Administration:
PCR Number
Attend#1 Name
Attend #2
Location Admin Occurred:
Gender of the Victim:
Patients Age:
Race/Ethnicity of the Victim:

Patient  Presentation

CC/ Provider Impression
Provider considers the following: (Check all that apply.)
If patient has a PMH of diabetes consider BGM prior to administration
Pre administration IMCRASS Score
Patients weight in kg:

Pre-administration Vital Signs

Heart Rate:
BP (if available)

Details of Ketamine Administration

Ketamne Administered? If No, please provide reason
Doses Used
How long did it take for the Ketamine to work?

Details of Post Ketamine Administration

Person's Response to Ketamine
Post Administration IMCRASS Score (see chart)
Post admin B/P
Post admin Heart rate
Post admin respiration
Post admin SPO2
Post admin End tidal CO2
ECG Rhythm:
Did the patient require intubation?
Transporting EMS Unit
Destination Hospital:
Post administration IMCRASS Score upon ED arrival
ED RASS Score (by ED Physician)
Medical Command Physician Name
Did the patient require additional sedation