Can Ketamine be used on a combative post-ictal patient or would Midazolam be the drug of choice in this case?
In brief: for the combative, post-ictal patient Midazolam would be the drug of choice if you require sedation in order to provide safe care for your patient.
Currently under the ALS-PCS v4.5, ketamine is only approved for use under the Combative Patient Medical Directive, with the indication of, Combative or violent or agitated behavior that requires sedation for patient safety. With the Other Condition of, Suspected excited delirium, severe violent psychosis. The OBHG ALS-PCS v4.5 Companion Document further specifies that Ketamine is to be used only for patients with suspected excited delirium, violent psychosis.
Midazolam, as a benzodiazepine, is the first line agent of choice for treatment of seizure, as well as the agent of choice for potential toxicologic causes of seizure: alcohol withdrawal and acute stimulant toxicity (without psychoses).
For a discussion on the need for pharmacologic agent in post-ictal patients, please see the Ask MAC from Apr 8, 2012.
Therefore, in this post-ictal combative patient population, Midazolam is the agent of choice.