# Ketamine



## Juxel (Apr 19, 2009)

Anyone use it?  We are dropping morphine and going to ketamine and versed for pain along with a variety of other things.  We still have dilaudid as an alternative, but morphine is out the door.


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## Street Doc (Apr 19, 2009)

What do you use for CP after the nitro?  Dilauded?


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## Juxel (Apr 19, 2009)

We do nitro drips and/or dilaudid.


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## Ridryder911 (Apr 19, 2009)

May I ask why? I am not a big fan of Morphine (especially those with bifasicular blocks) but Ketamine is kinda strong for most analgesic type situations. There was an article of another country (Australia?) usig it per local injections. 

I personally do not like Ketamine as the duration and variableness of it, I much prefer Fentanyl. 

R/r 911


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## Juxel (Apr 19, 2009)

Ridryder911 said:


> May I ask why? I am not a big fan of Morphine (especially those with bifasicular blocks) but Ketamine is kinda strong for most analgesic type situations. There was an article of another country (Australia?) usig it per local injections.
> 
> I personally do not like Ketamine as the duration and variableness of it, I much prefer Fentanyl.
> 
> R/r 911



I wish I could give you an answer.  Our medical director swears by it.  We've been doing a trial run with select individuals (I was not part of that as I don't work the streets often enough), and apparently the results have been outstanding.  I don't know if they were doing the trial run for publication or just for internal information.


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## Mountain Res-Q (Apr 19, 2009)

I have a lot of experience with Ketamine and love it... in Veterinary Medicine!
We use it as an induction agent (combined with Diazapam) for most surgerys.
I've only seen it used on a human once for short term anesthesia for a closed resuction of a silver fork fracture on a 5 year old.  I was told then by the Ortho Surgeon that Ketamine was not recommedned for anyone over 5 or 6 because older subjects have reported reoccuring nightmares of the procedures performed under Ketamine.  Along the same lines, ketamine (I Believe) is a drug occassionally used by SCUM to knock out rape victims, and that those victims often have those nightmares.  I've never heard of EMS using it in the field, and for those reasons I am amazed.  Does anyone know if there is any truth to this?

That said, from a Veterinary standpoint:  The effectivness of Ket/Val in Dogs and Cats is ~30 minutes and has some interesting side effects while come off of it, while morphine tends to remain effective longer and (with the exception of vomiting) has few sideeffects from our viewpoint.  Bt that is surgical on animals and not analgesia in humans in the field.  So for a typical surgical protocol for a spay/neuter we premed with morphine, induce wiht Ket/Val, intubate, and put them on an inhaled anesthesia.  Hydromorphone or Bupernorphine is usually used post-op.  Not that anyone cares, but just offering my 2 cents.   B)


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## medic417 (Apr 19, 2009)

Why do away with morphine, why not keep it as an option?  Or does the doctor fear your medics are not able to decide which drug is best for which patient?


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## LucidResq (Apr 19, 2009)

My close friend is a heart transplant recipient. I visited him in the cardiac ICU as they were placing a PIC line about a year after his transplant as he was having some issues and needed a continuous, long term IV. They were using ketamine, and probably other drugs, but apparently ketamine as the primary sedative. 

Seeing him in this extremely dissociated state makes me wonder how much this drug would impair proper assessment. Is this effect only achieved in high dosages not utilized prehospitally? I can imagine that if I took a pt. into the ED in the state my friend was in, they would be pissed at me. But this is my one and only experience with the drug, and I have little knowledge base in pharm. 

(As far as nightmares - my friend has no recollection of getting the line and does not have nightmares or any adverse effects that I'm aware of)


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## Flight-LP (Apr 19, 2009)

Ridryder911 said:


> May I ask why? I am not a big fan of Morphine (especially those with bifasicular blocks) but Ketamine is kinda strong for most analgesic type situations. There was an article of another country (Australia?) usig it per local injections.
> 
> I personally do not like Ketamine as the duration and variableness of it, I much prefer Fentanyl.
> 
> R/r 911



I second that motion...........

Ketamine is overkill, especially in the EMS arena. fentanyl is more controlled, shorter acting, and has less hemodynamic effects. Combine it with Etomidate and you got a great pain/sedation combo................


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## fma08 (Apr 19, 2009)

Ketamine does seem like an odd choice prehospitally... especially if it's for pain control... I also like fentanyl for prehospital use.


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## Melbourne MICA (Apr 20, 2009)

*Opiates*



Ridryder911 said:


> May I ask why? I am not a big fan of Morphine (especially those with bifasicular blocks) but Ketamine is kinda strong for most analgesic type situations. There was an article of another country (Australia?) usig it per local injections.
> 
> I personally do not like Ketamine as the duration and variableness of it, I much prefer Fentanyl.
> 
> R/r 911



I agree ryders but I'm still a fan of Morph. Opiates still have a role to play for some time. Cheap effective and when properly administered and titrated, low side effect problems. Bucket loads and decades of practical experience to call upon as well for all in the medical community at almost every level.

We use Methoxyflourane, Morph, Fentanyl and currently trialling Ketamine for fracture and trauma stuff. Each has a place.

Nitro isn't an analgesic and shouldn't be used as one. Won't be much help in a supposed ischaemic chest pain case that isn't ischaemic pain. I assume Dilaudid is used in conjunction with the nitro?

Interesting emergence side effects from the Ketamine.

MM

PS I think narcosis is better on/for many pts than anaesthesia especially when you are looking at suppressing the sympathetics.


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## Ridryder911 (Apr 20, 2009)

My Doc wants us to start Dilaudid but personally, I am not a fan of it. I have found it not to be much on real pain control and more of a "well we gave them something" type med. A favorite in the O.B. dept. He is fearful of Fentanyl due to the "stone chest syndrome" in which I cannot find any revent reports on. Personally, I believe it is foolish as it is a well controlled med as described and I have used numerous times as well as a maintenance drip to control pain along with sedatives as described. 

I too have heard about the Ketamine nightmare responses and that I why I was interested in the local injections versus IV route. Also, it a pain to continously monitor closely for a long period of time. I always seen it used for primary sedative with pain control. This might be an alternative way though to control break through pain and those with prolong transports. 

R/r 911


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## Juxel (Apr 20, 2009)

I haven't had our training on it yet, I have it this week.  I will let you guys know more about the standing orders and when/how we are intended to use it.  All the info I have on it so far is second hand from others who have had the training.


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## VGFDEMT34 (May 4, 2009)

Ridryder911 said:


> I much prefer Fentanyl.



+1

Fentanyl is definitely preferred over morphine. Only trouble is getting orders for it vs. morphine.


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## marineman (May 5, 2009)

We still only have morphine and dilaudid. We're hoping to get fentanyl soon but our medical director has had some bad luck lately with bad medics getting hired so he's completely changed our protocols so we really can't do much. It's a shame that patients have to suffer because a few people are in over their heads.


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## emtjack02 (May 5, 2009)

I don't know much about Ketamine other than it can be used for RSI especially in children and asthmatics.  As well as procedural sedation for peds.  I do like Dilaudid however one must be careful to push slowly or there is significant n/v. Also, with older women it seems they are more prone to hallucinations. I also wanted to point out that the ACC/AHA 2007 UA/NSTEMI guidelines state "A large observational registry that include pt w/ ua/nstemi suggested a higher adjusted likelihood of death with morphine."


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## omak42 (May 8, 2009)

Ridryder911 said:


> May I ask why? I am not a big fan of Morphine (especially those with bifasicular blocks) but Ketamine is kinda strong for most analgesic type situations. There was an article of another country (Australia?) usig it per local injections.
> 
> I personally do not like Ketamine as the duration and variableness of it, I much prefer Fentanyl.
> 
> R/r 911



whats the deal with morphine and bifasicular blocks?  never heard of the correlation before.....


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## Medix (Jun 23, 2009)

I'm surprised about you guys in the U.S. rarely use Ketamine. Here in Germany Ketamine (Ketanest-S) is a commonly used iv analgetic for trauma patients.
It ist used in combination with a benzodiazepine like Midazolam (Dormicum), that reduces the nightmare responses. The Esketamine (Ketamine S) we normally use is described with rare psychical effects than the racemate. We do have very good experiences with the Ketamine on trauma patients (also with Fentanyl) and the Ketamin is not under the anesthetic law here in Germany (like Fentanyl or Morphine), so we (Paramedics) can use it in the field.
Meanwhile we do have discussions with some Emergency Physicians about the usage by Paramedics because they say there is a high risk of adverse effects they don't can be mastered by Paramedics.


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## Shishkabob (Jun 23, 2009)

Medix said:


> Ketamin is not under the anesthetic law here in Germany (like Fentanyl or Morphine), so we (Paramedics) can use it in the field.



That probably explains it.

Paramedics can give out Morphine and Fentanyl here in the US even though they are opiod-based controlled substances, which are banned to the public.


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## Medix (Jun 23, 2009)

Is there any study about incidents of applying Fentanyl or Morphine by Paramedics in the US or do you have own experiences ?

In Germany, Physicians never would allow Paramedics to use these drugs.


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## Ridryder911 (Jun 23, 2009)

The reason Ketamine is rarely used here is the duration factor. Even in many ER's Ketamine has been replaced because of the dangers of respiratory depression and duration of the drug as well as some nasty side effects such as night terrors. 

Many EMS has opioid type analgesics and over all no problems as we carry an antagonist as well (Narcan). Pain control has been more emphasized in the past five years than before. 

R/r 911


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## Hastings (Jun 25, 2009)

Ketamine. Great for kids needing RSI...and horses.


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## PapaBear434 (Jun 25, 2009)

Hastings said:


> Ketamine. Great for kids needing RSI...and horses.



What about horses that need RSI?  Sure, you'd need a garden hose and a fiber optic camera...

Yeah, we don't use Ketamine.  The rational I've heard is it's pretty harsh and can have some wild reactions in a lot of folks, and it's effect lasts too long for the ER Doc's taste.


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## Hastings (Jun 25, 2009)

PapaBear434 said:


> What about horses that need RSI?  Sure, you'd need a garden hose and a fiber optic camera...
> 
> Yeah, we don't use Ketamine.  The rational I've heard is it's pretty harsh and can have some wild reactions in a lot of folks, and it's effect lasts too long for the ER Doc's taste.



I've never tried to RSI a horse (yet), but I have plans. And those plans involve a lot of Ketamine.

That being said, Ketamine really is the perfect drug for pediatric RSI.


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## mikie (Jun 25, 2009)

*Google wasn't much help.*

Can someone elaborate on the ketamine nightmares, terrors, etc?


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