Introduction: Violent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear. The objective is to demonstrate that ketamine, given as a single intramuscular injection for violent and agitated patients, including those with suspected excited delirium syndrome (ExDS), is both safe and effective during the prehospital phase of care, and allows for the rapid sedation and control of this difficult patient population. Methods: We reviewed paramedic run sheets from five different catchment areas in suburban Florida communities. We identified 52 patients as having been given intramuscular ketamine 4mg/kg IM, following a specific protocol devised by the EMS medical director of these jurisdictions, to treat agitated and violent patients, including a subset of which would be expected to suffer from ExDS. Twenty-six of 52 patients were also given parenteral midazolam after medical control was obtained to prevent emergence reactions associated with ketamine. Results: Review of records demonstrated that almost all patients (50/52) were rapidly sedated and in all but three patients no negative side effects were noted during the prehospital care. All patients were subsequently transported to the hospital before ketamine effects wore off. Conclusion: Ketamine may be safely and effectively used by trained paramedics following a specific protocol. The drug provides excellent efficacy and few clinically significant side effects in the prehospital phase of care, making it an attractive choice in those situations requiring rapid and safe sedation especially without intravenous access. [West J Emerg Med. 2014;15(7):–0.]