# Prehospital use of Ketamine



## FFEMT427 (Oct 5, 2011)

I would like to find prehospital providers who use ketamine for pain managment or any other use and what you think of it.


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## MagicTyler (Oct 5, 2011)

Not pre hospital, but I've saw a doc use it in the ED for a trauma with borderline pressures for RSI. Ketamine and succs.


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## STXmedic (Oct 5, 2011)

There's a lot of talk right now on us getting it (just talk so far). Our local HEMS uses it, but I don't have a lot of experience with it myself


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## the_negro_puppy (Oct 5, 2011)

FFEMT427 said:


> I would like to find prehospital providers who use ketamine for pain managment or any other use and what you think of it.



Out Intensive care paramedics carry it and use it for:

- Adjunct to morphine (0.1-0.2 mg/kg) in patients with severe traumatic pain associated with:

- Fracture reduction and splinting
-Multiple or significant fractures requiring facilitated extrication.

Dose- IV 10mg-20mg every 2-3 mins max dose 1mg per kg

I have not seen it used


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## usafmedic45 (Oct 5, 2011)

Wonderful stuff.  We have it on the air ambulance.  It's my first line drug for intubation of crashing asthmatics, hypotensive trauma patients and now there is some evidence that it has neuroprotective effects and might be beneficial in head trauma.  The old advice about avoiding it in head trauma to avoid increases in ICP appears to have no basis in evidence.

It is also ideal for pain control in severe burns and long bone fractures that are not controlled by morphine or fentanyl.


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## FFEMT427 (Oct 5, 2011)

usafmedic45 said:


> Wonderful stuff.  We have it on the air ambulance.  It's my first line drug for intubation of crashing asthmatics, hypotensive trauma patients and now there is some evidence that it has neuroprotective effects and might be beneficial in head trauma.  The old advice about avoiding it in head trauma to avoid increases in ICP appears to have no basis in evidence.
> 
> It is also ideal for pain control in severe burns and long bone fractures that are not controlled by morphine or fentanyl.



When you use it for RSI do you use it with sux vec or roc as your paralytic if sux is there a worry about useing the two together and causing increased ICP or is all of that unfounded
Thanks this is helpful


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## usafmedic45 (Oct 6, 2011)

> causing increased ICP or is all of that unfounded



It's pretty much unfounded.

As for using it with sux or vec, it depends.  Some patients you don't need to give a paralytic with but in almost every cases one is given along with the ketamine.  Also you should always give a benzodiazepine along with ketamine to avoid the emergence reaction that is well known to be the primary problem with use of ketamine.


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## Smash (Oct 6, 2011)

I'll second usaf, ketamine is a brilliant drug, extremely effective and very versatile.  Just make sure you don't push it too fast in big doses, or you might get a fright!


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## FFEMT427 (Oct 6, 2011)

Do you usually use versed or is there a better choise?


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## usafmedic45 (Oct 6, 2011)

Ativan is my benzo of choice for most things, but mostly due to my having more experience with it than anything else.


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## MrBrown (Oct 6, 2011)

Ketamine was introduced for our Intensive Care Paramedcs in 2007 and it's hands down the best bloody thing out there, absolutely brilliant stuff! 

We are using it at low doses for analgesia (preferably in combination with morphine but not an absolute requirement) and for induction prior to RSI.  For RSI we use it in combination with fentanyl, suxamethonium and vecuronium.

It's great stuff for burns, MSK pain/trauma and severe pain not responding to morphine which is primarily why we introduced it however it also posessed bronchodialatory effects and doesn't cause negative respiratory and circulatory problems like benzos and morphine can which makes it particularly useful in asthmatics and hypotensive trauma patients.  While our Intensive Care Paramedics have the option of using morphine+midazolam that has really fallen out of fashion now that everybody has ketamine, midazolam is not an analgesic and provides no pain-relieving properties whereas ketamine has profound analgesic effect at low doses.

As for the nightmares/hallucinations/emergence syndrome everybody is quick to point out I have not seen it in any of the patients ketamine has been administered to which include burns, NOFs and some bloke with a nunngered femur but I've seen one patient reckon his name was "banana" post-ketamine so you might want to keep some ice cream handy for an impromptu desert 

Oh, don't worry about increased intracranial pressure with ketamine, there are some studies out there I have read but am too lazy to look up which concluded it's like that whole don't give Grandpa with COPD oxygen thing; I know one was from the Israeli Defence Force. 

The only problem with using ketamine for analgesia is it's awful bloody wasteful; 200mg/2ml into a 100ml pack of D5 to make 2mg/ml means that you end up throwing out most of what was in the vial.


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## the_negro_puppy (Oct 6, 2011)

MrBrown said:


> The only problem with using ketamine for analgesia is it's awful bloody wasteful; 200mg/2ml into a 100ml pack of D5 to make 2mg/ml means that you end up throwing out most of what was in the vial.



Some for the patient and some for Brown when he gets home for the weekend?


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## usafmedic45 (Oct 6, 2011)

> Some for the patient and some for Brown when he gets home for the weekend?



Is the stuff used as a party drug down there like it is used in some circles up here?  If it is, that would explain how Brown is getting his hands on it.


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## MrBrown (Oct 6, 2011)

usafmedic45 said:


> Is the stuff used as a party drug down there like it is used in some circles up here?  If it is, that would explain how Brown is getting his hands on it.



Yes it is

I never did drugs, well, not personally, gave them to other people tho, but they all came out the green pack


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## FFEMT427 (Oct 6, 2011)

The justification for using it in asthmatics is due to its bronchodialatory effect right. Do you the the sedative effect of the med helps out as well. And what sort of doses are you using in asthmatics?


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## MrBrown (Oct 6, 2011)

FFEMT427 said:


> The justification for using it in asthmatics is due to its bronchodialatory effect right.



Yes



FFEMT427 said:


> Do you the the sedative effect of the med helps out as well. And what sort of doses are you using in asthmatics?



Ketamine for use with asthmatics is given as an induction agent to provide anaesthesia for intubation, so yes we are utilising the hypnotic/amnestic properties of it for exactly that reason, the bronchodialatory effect is just a nice add on.  

Induction dosage is 1.5mg/kg here but I have seen anything from 1-3mg/kg in the literature/textbooks.

Ketamine has no sedating property on the central nervous system like morphine or a benzo per-se rather it is a disassociative anaesthetic that (for want of a better description) acts as a NMDA blocker and "disconnects" the limbic system from the higher brain centres (I think the hypothalmus) to produce a state of disassociation rather than one of traditional sedation or GABA-blockade anaesthesia.


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## usafmedic45 (Oct 6, 2011)

> Do you the the sedative effect of the med helps out as well. And what sort of doses are you using in asthmatics?



Nah, it's primarily the bronchdilatory effect (the catecholamine release).  The dose is the same as for any other anesthesia induction with ketamine.



> Ketamine for use with asthmatics is given as an induction agent to provide anaesthesia for intubation, so yes we are utilising the hypnotic/amnestic properties of it for exactly that reason, the bronchodialatory effect is just a nice add on.



Actually, speaking from experience with it, the primary reason for its use by medical professionals is its bronchodilatory effects.  There's no hypnotic/amnestic effect since it's an anesthetic not a sedative.  Any other benefit normally associated with its use are cancelled out by the fact that it's chased with paralytic in most cases. 



> Ketamine has no sedating property on the central nervous system like morphine or a benzo per-se rather it is a disassociative anaesthetic that (for want of a better description) acts as a NMDA blocker and "disconnects" the limbic system from the higher brain centres (I think the hypothalmus) to produce a state of disassociation rather than one of traditional sedation or GABA-blockade anaesthesia.


Then it does not have a hypnotic/amnestic effect.  Either it's a dissociative anesthesia or it's a hypnotic/amnestic (think Versed).


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## bradford (Oct 7, 2011)

I have never personally used Ketamine as an analgesic or anaesthetic (saw my college roommate get dosed for a dislocation reduction in the E.R. though, that was hilarious) and only used etomidate once for RSI purposes during my hospital clinicals, but I have heard that Ketamine is preferable to Etomidate in anesthesia and RSI applications because of less adrenal suppression, especially in prolonged infusion rates. Is there a possibility that Ketamine and Fentanyl will take the place of Etomidate and Morphine in the prehospital field?


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## Smash (Oct 7, 2011)

bradford said:


> Is there a possibility that Ketamine and Fentanyl will take the place of Etomidate and Morphine in the prehospital field?



I think there is.  The real danger of etomidate in the critically unwell patient hasn't been fully elucidated.  There is no doubt that even a single dose causes a suppresion of the adreno-corticoid axis, but what isn't clear is whether this actually has any clinical effect in the long run.  I think there is still a lot of research to be done before we throw away etomidate, however in the meantime, given the choice, I would almost always pick ketamine as my first line agent.

I don't think that it will replace morphine.  Morphine is mostly effective, relatively safe and everyone is very comfortable with it due to it's long history.  It will certainly augment it however, as it really is a wonderful drug for analgesia in certain settings.


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## FFEMT427 (Oct 7, 2011)

Smash said:


> I think there is.  The real danger of etomidate in the critically unwell patient hasn't been fully elucidated.  There is no doubt that even a single dose causes a suppresion of the adreno-corticoid axis, but what isn't clear is whether this actually has any clinical effect in the long run.  I think there is still a lot of research to be done before we throw away etomidate, however in the meantime, given the choice, I would almost always pick ketamine as my first line agent.
> 
> I don't think that it will replace morphine.  Morphine is mostly effective, relatively safe and everyone is very comfortable with it due to it's long history.  It will certainly augment it however, as it really is a wonderful drug for analgesia in certain settings.



i agree completely that fent will not replace MS however due to its quick action and short halflife i think it will and should be used more. However to take away MS completely is to take away a tool and a great tool at that.


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## McGoo (Oct 7, 2011)

We use ketamine as a second line analgesic for traumatic pain after fentanyl or methoxyflurane. It's an awesome drug that gives excellent relief. 

We give 10mcg/kg IM, and 1mcg/kg IV/IO, repeat until effective at 10 and 3 minute intervals respectively.


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## jwk (Oct 7, 2011)

Those of you who don't think there is a problem with ketamine and hallucinations are very badly mistaken.  It doesn't happen all the time - but it most definitely occurs.


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## FFEMT427 (Oct 7, 2011)

jwk said:


> Those of you who don't think there is a problem with ketamine and hallucinations are very badly mistaken.  It doesn't happen all the time - but it most definitely occurs.



I dont belive anyone said that it did not. infact it was mention to use benzo's for the emergence reactions
So far very good info thanks everyone


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## systemet (Oct 8, 2011)

A couple of quick opinions:

* Drugs are tools.  Morphine is a great analgesic.  It has some limitations in certain patient populations.  I don't think it's going anywhere.  It still has a very useful place in systems that use fentanyl.

* Same thing with benzodiazepines.  Ketamine just provides a better option in some hypotensive patients, and intubating patients with reactive airway disease.  

* I think in EMS we define ourselves based on scope of practice and the breadth of our protocols.  If we see someone with a greater scope, more toys, and the newest medications, we assume their system is better.  I think that it's often possible that a system with a more restrictive scope / protocols, but better QI / con-ed / medical director involvement may provide superior patient care.

* I think we need to move past a certain fascination with new medications and scope expansion, and focus on getting a decent base education if we want to professionalise EMS.

None of this is directed at anyone in particular.  Just a couple of opinions.


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## medicsb (Oct 8, 2011)

systemet said:


> A couple of quick opinions:
> 
> * I think in EMS we define ourselves based on scope of practice and the breadth of our protocols.  If we see someone with a greater scope, more toys, and the newest medications, we assume their system is better.  I think that it's often possible that a system with a more restrictive scope / protocols, but better QI / con-ed / medical director involvement may provide superior patient care.
> 
> * I think we need to move past a certain fascination with new medications and scope expansion, and focus on getting a decent base education if we want to professionalise EMS.



Seriously.  There is nothing "progressive" about blindly introducing (or maintaining) a skill or drug without evidence to support its use, or without studying it to produce data to determine its utility and safety.  All EMS systems are guilty of this, but some more-so than others, for sure.


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## Smash (Oct 8, 2011)

I don't  disagree with the sentiments of the last two posts, but they are not apposite to the conversation about ketamine. 

Also jwk: huh?


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## Remeber343 (Oct 8, 2011)

* Drugs are tools.  Morphine is a great analgesic.  It has some limitations in certain patient populations.  I don't think it's going anywhere.  It still has a very useful place in systems that use fentanyl.


Our county still carries Morphine, but we rarely use it.  As said, it has its place, but mainly we have been using Dilaudid for pain management.  It seems some of the seasoned medics still use Morphine over Dilaudid, and i'm not sure if this is because they are more comfortable with it, studies have shown that Dilaudid is 3-4x stronger then Morphine, and still has the same affect w/fentanyl as morphine does.  Any of you guys have input on why to use either/or.


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## jjesusfreak01 (Oct 8, 2011)

jwk said:


> Those of you who don't think there is a problem with ketamine and hallucinations are very badly mistaken.  It doesn't happen all the time - but it most definitely occurs.



I know the hospitals in my area use Ketamine readily for pediatric sedation, but not for adults for that very reason. I do like the idea of using it with Benzos to prevent this, but I also don't like overdosing patients with psychoactive drugs...


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## usalsfyre (Oct 8, 2011)

Smash said:


> I don't  disagree with the sentiments of the last two posts, but they are not apposite to the conversation about ketamine.
> 
> Also jwk: huh?


+1

Ketamine is not a "new" drug. It simply hasn't been popular in the US due to other factors.


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## FFEMT427 (Oct 8, 2011)

systemet said:


> A couple of quick opinions:
> 
> * Drugs are tools.  Morphine is a great analgesic.  It has some limitations in certain patient populations.  I don't think it's going anywhere.  It still has a very useful place in systems that use fentanyl.
> 
> ...



I actually never meant this thread to be about looking for "new" medications (not sure if you are refering to ketamine since its been around for awhile) or "scope expansion" I wanted to talk to people who use the medication in therapy of the ill and injured. 
In my opinion the amount of drugs in my drug box and the amount of medic voodoo in my scope of practice means nothing. If any treatment we provide regardless of how long it has been in place was not for the best of our patients we should not use it. The goal of this type of discussion and medical study's testing new medications and treatment in the field is to enhance our ability to care for our patients since that is what our mission is. That being said I understand where you are coming from there is a focus from some that always are looking for something new just because there service doesnt have it. I assure you that was not my intention.


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## tssemt2010 (Oct 9, 2011)

works great on super combative patients


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## FFEMT427 (Oct 9, 2011)

tssemt2010 said:


> works great on super combative patients



Your protocols allow for it to be used as a chemical restraint? Ive never heard of that being done just seditaves and haldol that sort of thing.


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## tssemt2010 (Oct 9, 2011)

FFEMT427 said:


> Your protocols allow for it to be used as a chemical restraint? Ive never heard of that being done just seditaves and haldol that sort of thing.



if our supervisor feels its appropriate than the supervisor can give it, paramedics cant give it unless a supervisor is on scene


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## alphatrauma (Oct 9, 2011)

Smash said:


> ...  Just make sure you don't push it too fast in big doses, or you might get a fright!



I've seen the aftermath of pushing it too quickly (apnea). Just make sure you have airway equipment [and suction for vomiting] handy, as you probably WILL be assisting with ventilations. 

We use it (in hospital) for reductions of fractures/dislocations, and minor surgical procedures in pediatrics. It does have an excellent sedative/amnesia effect, but I'm not totally sold on analgesia. 

At my recent ACLS recert class, I had a cardiologist (of 39 years) blast the use of Ketamine in adults due to it's psychotropic effects... "it's for horses", she said.


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## usafmedic45 (Oct 9, 2011)

tssemt2010 said:


> works great on super combative patients



Nice....nothing like giving a chemical "cousin" of PCP to a combative patient.  Underdosing could make things worse....


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## FFEMT427 (Oct 9, 2011)

usafmedic45 said:


> Nice....nothing like giving a chemical "cousin" of PCP to a combative patient.  Underdosing could make things worse....



Yeah I think there are better alternatives for chemical restraint personaly but to each his own (I guess)


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## usafmedic45 (Oct 9, 2011)

FFEMT427 said:


> Yeah I think there are better alternatives for chemical restraint personaly but to each his own (I guess)



That or more likely he either misunderstood why the ketamine was being used or is simply lying.


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## tssemt2010 (Oct 9, 2011)

usafmedic45 said:


> Nice....nothing like giving a chemical "cousin" of PCP to a combative patient.  Underdosing could make things worse....



and thats exactly why they only let supervisors here push it, we typically give versed but there has been one case in the year ive been here where we used ketamine on a guy, wouldve been easier if the police on scene had done there jobs but they refused to handcuff him because they didnt want to ride into the hospital with us


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## STXmedic (Oct 9, 2011)

tssemt2010 said:


> and thats exactly why they only let supervisors here push it, we typically give versed but there has been one case in the year ive been here where we used ketamine on a guy, wouldve been easier if the police on scene had done there jobs but they refused to handcuff him because they didnt want to ride into the hospital with us



He wasn't bad enough for cuffs, but he was bad enough for ketamine?


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## Remeber343 (Oct 9, 2011)

Question, why do the paramedics need a supervisors aproval to push a drug under their belt?  I understand medical control, but out here, the "supervisor" on scene on a medical call, is the paramedic.  I'm kind of confused on who the supervisor is you are talking about?


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## medicsb (Oct 9, 2011)

PennStar (aeromedical component of the Hospital of the University of Pennsylvania) has a protocol for administering ketamine to combative trauma patients for whom they cannot establish an IV.  After the ketamine, they're to establish an IV or IO and then RSI.  It's a very rarely used protocol from what I understand.


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## Smash (Oct 9, 2011)

alphatrauma said:


> At my recent ACLS recert class, I had a cardiologist (of 39 years) blast the use of Ketamine in adults due to it's psychotropic effects... "it's for horses", she said.



With all due respect to the doctor, how much experience do you think a cardiologist would have with ketamine, as opposed to an emergency physician or anaesthesiologist?   

That comment sounds like someone who does not understand the drug, or who is hanging on to deeply engrained prejudice in the face of the evidence that ketamine is a relatively safe, very effective and versatile medication.

The emergence phenomenon is reasonably well understood, not hugely common, and easily managed.


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## usafmedic45 (Oct 9, 2011)

Remeber343 said:


> Question, why do the paramedics need a supervisors aproval to push a drug under their belt?  I understand medical control, but out here, the "supervisor" on scene on a medical call, is the paramedic.  I'm kind of confused on who the supervisor is you are talking about?



Usually a senior provider.  The service I worked at we had additional skills as more experienced ALS provider than the "regular" guys because our medical director found it easier to keep the smaller number of supervisors adequately trained and qualified on the less frequent procedures than to try to maintain it and dilute the experience by allowing everyone to do it.


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## usafmedic45 (Oct 9, 2011)

tssemt2010 said:


> and thats exactly why they only let supervisors here push it, we typically give versed but there has been one case in the year ive been here where we used ketamine on a guy, wouldve been easier if the police on scene had done there jobs but they refused to handcuff him because they didnt want to ride into the hospital with us



I call bull:censored::censored::censored::censored:.  There's no reason to use ketamine like that when better options exist.  



> PennStar (aeromedical component of the Hospital of the University of Pennsylvania) has a protocol for administering ketamine to combative trauma patients for whom they cannot establish an IV. After the ketamine, they're to establish an IV or IO and then RSI. It's a very rarely used protocol from what I understand.



It doesn't sound like the same scenario the newbie is talking about.  What you're describing is a well established practice to gain airway control.  What he seems to be describing is simply to knock the patient down for the convenience of all involved with a drug never intended for use like that (at least in humans).


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## usalsfyre (Oct 9, 2011)

I think I know the system he's referring to, and they do actually use ketamine for chemical restraint. I don't know if the above use is what I would have done though.


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## tssemt2010 (Oct 10, 2011)

usafmedic45 said:


> I call bull:censored::censored::censored::censored:.  There's no reason to use ketamine like that when better options exist.
> 
> 
> 
> It doesn't sound like the same scenario the newbie is talking about.  What you're describing is a well established practice to gain airway control.  What he seems to be describing is simply to knock the patient down for the convenience of all involved with a drug never intended for use like that (at least in humans).


im not sure what my supervisors reasoning for it was but it sure as hell was ketamine


usalsfyre said:


> I think I know the system he's referring to, and they do actually use ketamine for chemical restraint. I don't know if the above use is what I would have done though.



i would have gone for versed as apposed to ketamine for sure, but not my decision, or my report so it didnt make a difference to me, wouldve been much easier if the cops had just restrained his *** to begin with, we also have extremely aggressive protocols, only things supervisors are on scene for is RSI and thats because of a problem an agency we mutual aid with had, and we do not use medical control for anything, all standing orders


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## systemet (Oct 10, 2011)

FFEMT427 said:


> The goal of this type of discussion and medical study's testing new medications and treatment in the field is to enhance our ability to care for our patients since that is what our mission is. That being said I understand where you are coming from there is a focus from some that always are looking for something new just because there service doesnt have it. I assure you that was not my intention.





> *Smash: *I don't disagree with the sentiments of the last two posts, but they are not apposite to the conversation about ketamine.



Sorry if I derailed the thread.  I agree that having a discussion about ketamine, or other medications is worthwhile and productive.

I share the reservations of previous posters about using ketamine as chemical restraint.


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## dmiracco (Oct 10, 2011)

We use Ketamine in the prehospital setting and I can tell you that it is a great and fairly safe medication when given appropriately.


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## usafmedic45 (Oct 10, 2011)

dmiracco said:


> We use Ketamine in the prehospital setting and I can tell you that it is a great and fairly safe medication when given appropriately.



That's most medications.  It's when you use them inappropriately that they bite you in the ***.


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## redcrossemt (Oct 13, 2011)

One of our air providers uses it for intubation. I am not sure if they use it for analgesia or painful procedures, but have definitely seen good results with it in the hospital. 

Possibly of interest to others, I really like West Michigan Air Care's MAI protocol chart and the discussion that accompanies it here:

http://www.aircare.org/pdfs/AirWaves_Vol13No2.pdf

http://www.aircare.org/pdfs/AirWaves_Vol13No3.pdf

http://www.aircare.org/pdfs/AirWaves_Vol13No4.pdf

http://www.aircare.org/pdfs/AirWaves_Vol13No5.pdf


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