Death of Elijah McClain

Virgil

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Hello everyone, I had a question and wanted to bring this to everyone’s attention, for those who haven’t followed.

Here is a snippet from the Wikipedia article that you can find here.

“The three police officers who were involved in the incident, said that their body cameras were knocked off during a struggle with him. While being held to the ground by police, paramedics administered ketamine to sedate McClain, who then went into cardiac arrest. McClain died seven days later after being removed from life support. McClain's autopsy was inconclusive.”

In another part of the article, it says that medics administered “500mg of ketamine as a sedative to reduce his agitation. McClain vomited several times while being held down, and suffered two cardiac while being taken to the hospital. He was pronounced brain dead on August 30, 2019.”

The coroner could not accurately determine cause of death but narrowed it to two possible conclusions: idiosyncratic drug reaction, or asthma attack.

My question, is 500mg enough to kill someone? Is that the normal dosage for chemical restraint? What would you have done in this situation?

This post is not to insinuate or assign blame, strictly for curiosity and education of the emergency medical treatment related to the incident. Also, if this post violates any guidelines or is in the wrong sub forum, please let me know.
 

NPO

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My question, is 500mg enough to kill someone? Is that the normal dosage for chemical restraint? What would you have done in this situation?
500mg is certainly enough to kill someone in the right circumstances. Agitated delirium is certainly one of those circumstances. 500mg is also a safe dose and is commonly accepted as a reasonable dose. Now, I'm not advocating against ketamine for AD; Ketamine has a wide safety profile, and is effective in chemically restraining someone. However, AD has a shockingly high mortality rate. Just as all medications has risks, so does ketamine.

AD can be thought of as a "sympathetic storm" and ketamine has sympathetic properties through it's stimulation of the adrenal gland to release catecholamines. This can push an AD patient over the edge to cardiac arrest. In these circumstances it's certainly hard to "blame" the medication or the providers, especially if they're following protocol.

I will add, anecdotally from my own experience, for AD patients or patients who experience side effects from ketamine, Versed on top of it seems to really ease things. This makes sense for AD patients since benzodiazapines are a CNS depressant and will help supress the catecholamine surge. I don't have any evidence for this, so if anyone can provide some for or against I would be interested to see it, but for now, it works for me.
 

FiremanMike

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We are at 3mg/kg IM currently but we used to be at 4mg/kg which would regularly end up being 500mg, so In a vacuum, 500mg of ketamine is not a cause of death. As NPO mentioned, versed must be coadministered to these patients every time...

Ultimately, we’re only getting a small part of this story. It’s not your fault, but there just isn’t enough here to really weigh in.
 

silver

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500mg is certainly enough to kill someone in the right circumstances. Agitated delirium is certainly one of those circumstances. 500mg is also a safe dose and is commonly accepted as a reasonable dose. Now, I'm not advocating against ketamine for AD; Ketamine has a wide safety profile, and is effective in chemically restraining someone. However, AD has a shockingly high mortality rate. Just as all medications has risks, so does ketamine.

AD can be thought of as a "sympathetic storm" and ketamine has sympathetic properties through it's stimulation of the adrenal gland to release catecholamines. This can push an AD patient over the edge to cardiac arrest. In these circumstances it's certainly hard to "blame" the medication or the providers, especially if they're following protocol.

I will add, anecdotally from my own experience, for AD patients or patients who experience side effects from ketamine, Versed on top of it seems to really ease things. This makes sense for AD patients since benzodiazapines are a CNS depressant and will help supress the catecholamine surge. I don't have any evidence for this, so if anyone can provide some for or against I would be interested to see it, but for now, it works for me.
He weighed 63 kg (140 lbs), so for agitation (around 3-4mg/kg) that’s not the most reasonable dose for sedation but rather an induction dose for general anesthesia. Co-administration of benzodiazepines helps with emergence. People report terrible vivid dreams/nightmares, so it definitely helps when you can’t remember that.
 

FiremanMike

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He weighed 63 kg (140 lbs), so for agitation (around 3-4mg/kg) that’s not the most reasonable dose for sedation but rather an induction dose for general anesthesia. Co-administration of benzodiazepines helps with emergence. People report terrible vivid dreams/nightmares, so it definitely helps when you can’t remember that.
Wow, that patient got nearly 8mg/kg..


There's a good article on pubmed about what happens with Ketamine toxicity..
 

NPO

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"Gable et al. determined the oral ketamine safety ratio for rodents as 25, and estimated that the median lethal dose averaged at 600mg/kg or 4.2g for a 70kg human."

Bit more than 8mg/kg
Your point is received, but that's also enteral versus parenteral routes.
 

Seirende

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I wouldn't use the phrase "possibly implicated with murder" for this case, just going off the face of it. The ketamine potentially contributed to Mr. McClain's death, but I doubt that the medics had the faintest shadow of intention to harm him.
 

E tank

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I doubt it was the ketamine per se...the dose in that size of a guy would be enough to obtund airway reflexes and in a non-fasted, struggling person, gastric regurgitation and aspiration would be a predictable consequence. It's the reason for the 'R' in RSI.
 

Seirende

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Your point is received, but that's also enteral versus parenteral routes.
Just a quick Google came up with this from the WHO.
(Critical review of KETAMINE)

"Applying the same ratio of minimal anaesthetic dose to highest non-lethal dose to humans implies that doses above 11.3 mg/kg i.v. may be lethal in humans. For a person of 60 kg this is equivalent to i.v. doses above 680 mg. This estimate is based on an experiment with a low number of animals and interindividual and interspecies differences may exist. Yet, considering data from case reports of fatal ketamine intoxications in humans, this estimate seems to be a realistic one."

So your point is fair.
 

FiremanMike

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"Gable et al. determined the oral ketamine safety ratio for rodents as 25, and estimated that the median lethal dose averaged at 600mg/kg or 4.2g for a 70kg human."

Bit more than 8mg/kg
Ok? I was commenting on the high dose and providing some info on some of the more severe side effects that can occur with ketamine..
 

Seirende

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Ok? I was commenting on the high dose and providing some info on some of the more severe side effects that can occur with ketamine..

I read it as you saying that 8 mg/kg was a toxic dose.
 

Seirende

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No, he was reacting to the conversation that 4mg/kg and 500mg are "normal" doses and that the patient received 8mg/kg.
I got that after he clarified, yes.

Perhaps you thought "read" was present tense.
 

Peak

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"Gable et al. determined the oral ketamine safety ratio for rodents as 25, and estimated that the median lethal dose averaged at 600mg/kg or 4.2g for a 70kg human."

Bit more than 8mg/kg
Just a quick Google came up with this from the WHO.
(Critical review of KETAMINE)

"Applying the same ratio of minimal anaesthetic dose to highest non-lethal dose to humans implies that doses above 11.3 mg/kg i.v. may be lethal in humans. For a person of 60 kg this is equivalent to i.v. doses above 680 mg. This estimate is based on an experiment with a low number of animals and interindividual and interspecies differences may exist. Yet, considering data from case reports of fatal ketamine intoxications in humans, this estimate seems to be a realistic one."

So your point is fair.
LD50 is what is typically reported as the lethal dose. When you look at toxicology it is important to remember that the LD50 is an average, and that many subjects have a higher or lower individual lethal dose.

Typically the LD50 is reported based on testing on lab rats or rabbits, so there is always a reasonable chance that the LD50 will be different in humans.

Clinically I have seen bradypnea requiring supplemental ventilation in some patients with a dose of less than 2mg/kg IV, and I know of a local case of a respiratory arrest that resulted in two days in the unit tubed (with zero additional sedation) as a result of a medication error where the patient got about 10 mg/kg IV. These certainly are outliers but clinically relevant to keep in mind.
Typically when we give ketamine for conscious/twilight intubation the patient typically will become partially dissociated at 0.25 mg/kg IV when pushed over about 30 seconds.

When we give ketamine for excited delirium our standard dose is 4-6 mg/kg IM or 1-2 mg/kg IV.
 

Peak

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When judging these cases people tend to forget that patients with Excited Delirium have a high risk of sudden cardiac death regardless.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5061757/
I thought most of the deaths of excited delirium are attributed to acute drug intoxicated, typically cocaine, PCP, meth, or synthetics (spice/bath salts). I assume the patient would have had a drug screen in the hospital and from the coroner.
 

hometownmedic5

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Your point is received, but that's also enteral versus parenteral routes.
Asked from a position of bewildered ignorance, is there a medication in the usp you could take 150x the amount of enterally vs. parenterally? I can’t think of one, but there’s probably one or two zany examples.
 

VFlutter

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I thought most of the deaths of excited delirium are attributed to acute drug intoxicated, typically cocaine, PCP, meth, or synthetics (spice/bath salts). I assume the patient would have had a drug screen in the hospital and from the coroner.

"Persons at risk for excited delirium are most likely at the extreme end of the neuropsychiatric continuum of several DSM-IV recognized disorders, including delirium induced by a drug, manic excitement, and psychomotor agitation (Vilke et al., 2012). Those at risk for excited delirium and sudden death include people who are withdrawing from or non-compliant with psychotropic drugs, substance abusers suffering from reward deficiency syndrome or alcoholics in withdrawal, and persons suffering from acute manic episodes that may be triggered or worsened by sleep deprivation."

Is probably most associated with illicit drug use however can still occur with prescription antipsychotics, withdrawal from them, or with underlying mania.
 

Carlos Danger

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Asked from a position of bewildered ignorance, is there a medication in the usp you could take 150x the amount of enterally vs. parenterally? I can’t think of one, but there’s probably one or two zany examples.
Yes. Can’t say I can think of a good example offhand, but many IV formulations simply aren’t bioavailable enterally.
 

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