# Ketamine



## Craig Alan Evans (Sep 1, 2012)

We just started using Ketamine to control combative/psychotic behavior. We used to throw buckets of Versed/Benadryl/Haldol at them.  They would take a good nap later but it would never control the acute behavior. One dose of Ketamine And they start starring at the walls quietly. It's a real life saver. Does anyone have experience with K?


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## Anjel (Sep 1, 2012)

I have just seen it used in the hospital. 

It was for conscious sedation for a 8 y.o who broke his radius and ulna. 

I wasn't impressed, just because the kid was still yelling and moving around. 
They repeated the dosage 2 times, but still couldn't achieve the desired effect. 

But like I said that is my only experience with it. I think it would be wonderful to have for psychs.


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## Doczilla (Sep 2, 2012)

You name it buddy. RSI, dental extractions, fracture reductions, chest tubes...


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## bigbaldguy (Sep 2, 2012)

Very useful as I understand it but no experience with it. I believe our service either just got it or is looking into it. 

I too have seen psych patients who bounce benzos off like bullets off superman.


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## Shishkabob (Sep 2, 2012)

My one experience with Ketamine includes a 3yo with a bloody hand doing the thousand yard stare at me and saying "Hello" in the creepiest voice ever.




My agency just replaced Etomidate with Ketamine for RSI due to the shortage... should be interesting.


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## Craig Alan Evans (Sep 2, 2012)

Yeah, Ketamine is used extensively for pediatric induction and conscious sedation. We haven't delved into that realm yet but it may be down the road.


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## abckidsmom (Sep 2, 2012)

Linuss said:


> My one experience with Ketamine includes a 3yo with a bloody hand doing the thousand yard stare at me and saying "Hello" in the creepiest voice ever.
> 
> 
> 
> ...



I had a 4 yo in the ER once who had a fake thumbnail up behind a turbinate.  The versed made him very loving.  He spent the half hour after the nail was out of his nose gazing lovingly at his mom, petting her face and saying "Mooooommmmy>.....I looooooooove yooooooooo."

I love kids on drugs.


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## abckidsmom (Sep 2, 2012)

Having made an off topic comment, I feel compelled to answer the initial question.

Working in these backwoods means no Ketamine.  For whatever reason, we only carry our EMS council's drug box and are limited to what they want to carry for all the providers across 9ish rural counties with two small cities.  

Progression to stocking our own drugs is slow.  Like slower than your 9 year old dawlding over homework on a Sunday night slow.


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## jwk (Sep 2, 2012)

Anjel1030 said:


> I have just seen it used in the hospital.
> 
> It was for conscious sedation for a 8 y.o who broke his radius and ulna.
> 
> ...



Then clearly the people at your hospital had NO clue what they were doing.  Ketamine doesn't "not work".  My guess would be that they were significantly underdosed or didn't have the IV in.


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## Doczilla (Sep 2, 2012)

Yup. Give it to em till they're dreaming in Chinese.


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## the_negro_puppy (Sep 2, 2012)

I saw Ketamine used in RSI the other day medium sized male pt got 80mg IV


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## Doczilla (Sep 2, 2012)

Two pearls for ketamine. Airway secretions can increase significantly, so in the event of visualization issues, (or dental work) premedication with a small dose of atropine may help. 

Also, be prepared to manage vomiting if you're using it for PSA. After learning the hard way, I now preemptively give zofran. 

Older children and adults may benefit from small doses of midazolam to prevent emergence delerium. Basically, takes the edge off a bad trip.


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## enjoynz (Sep 3, 2012)

Ketamine has been used on the ambulance in New Zealand for a while now.
As I can't just copy and paste the info on Ketamine this person has written about, I've attached the link.
Some of you may find it an interesting read, as it covers a great deal about the NZ Ambulance Service, along with pain assessment and pain alleviation practises.

http://aut.researchgateway.ac.nz/bitstream/handle/10292/1401/WernerS.pdf?sequence=3


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## jroyster06 (Sep 4, 2012)

We us it for excited delirium, RSI (or etomidate, our choice), and for dissociating pt's for procedures. 

The IM dose takes awhile for full effectiveness. Usually When i use it for excited delirium its the IM dose as soon as they are sedated enough get an iv ASAP and get ready to give more just because the IM does not work nearly as well as IM...obviously. 

It also causes a lot of oral secretions, minor suctioning will probably be needed. I have been wondering if nebulizing atrovent may work to dry secretions instead of using atropine that way you avoid extra tachycardia, but its not in our local protocols.


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## Doczilla (Sep 4, 2012)

Provided that you're outside the relative contraindication zone, .5mg of atropine isn't gonna do much. A lot of times, you get a paradoxical parasympathetic response, and don't see any tachycardia. 

Ketamine is gonna Jack up their heart rate anyway.


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## medicsb (Sep 4, 2012)

Ketamine seems to be getting a lot of hype these days.  Though, I think it has some potential uses, I worry that it is being adopted without much thought.  Is there any evidence that ketamine is better than a benzodiazepine for severely agitated patients?  Is there any evidence that ketamine is superior to etomidate?  Of any EMS carrying it, how many are studying it?


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## Doczilla (Sep 4, 2012)

I don't think its sudden hype, I think we realized how underutilized it is.

The issue with etomidate is that it does not provide any analgesic properties. Outside of the induction window, maintence sedation is required with analgesia. (Propofol/fentanyl, midazolam/fentanyl, etc) For most EMS providers that use etomidate, they are usually at the hospital before this is an issue, or have some type of maintenence sedation protocol. Serial doses of etomidate are not an option. They learned that lesson the hard way in burn units. 

Ketamine provides both anesthesia, and profound analgesia. It's not a wonder drug by any means, but this it does well. 

For chemical restraint, I wouldn't say that one drug is superior over the other. However, there are benefits of inducing a complete disassociative state, although doses as high as 5mg/kg IM may be needed. 

Basically, if you want to knock them on their a$$ instead of just taking the edge off, ketamine is the drug. I don't see many anti-psychotics used in EMS.


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## Another German (Sep 9, 2012)

Hello,

in Germany the usage of (S) Ketamine in combination with a benzodiazepine (usually Midazolam)  is quite common. Often used for fractures and also unstable trauma patients with low pressure. I never used (S) Ketamine for any kind of agitated patients. Might be the problem that it is forbidden for this usage by the producer.


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## GorillaMedic (Sep 9, 2012)

We have ketamine in our protocols for RSI and excited delirium. I've personally only used it for RSI and found it works pretty great—with a few caveats. It takes a little longer to hit than etomidate does; we wait for evidence of sedation before pushing paralytics. We've seen a few instances of brief, transient laryngospasm (that seems to clear up after a few seconds). In severely hypertensive patients, our medical director wants us to also push versed to counteract the effects of ketamine on BP.

Overall, though, ketamine seems to work pretty well. Our dose is 1-1.5 mg/kg IV (usually, we just give the same amount as our succinylcholine) for RSI, 5 mg/kg IM for excited delirium. What are the rest of you using for dosing?


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## clearblueskies (Sep 13, 2012)

We use the CRAP out of it on our aircraft and not just for sedation. Let me let you in on a little secret that many physicians, services and even pharmacists don't yet know about this EXTREMELY old drug. It can be used in subdissociative dosing for analgesia that is 1000 times better then Dilaudid, Fentanyl or Morphine. The dosing for pain relief is 0.1mg/kg and may be repeated every 5-10 minutes. Our protocol on our aircraft and ambulances state that this is the go to for pain relief in any severe trauma situation or any obvious fracture or dislocation. The nice thing is that it totally gets rid of the pain and does not sedate your patient, and when you have trauma with low blood pressure it can actually help to slightly increase their blood pressure. The neat thing is that it for what ever reason ( still unknown) it does not artificially increase the blood pressure of a normotensive or hypertensive patient! As far as sedation, people are always afraid that it will cause reemergence phenomenon and that can occur. However we use it for sedation and induction during RSI about 10 to 15 times a month and we might get one person a month who ends up with reemergence, and this is easily taken care of with 1-2 mg of ativan. Just some useful information.


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## EMT11KDL (Mar 6, 2015)

I'm bringing this thread back to life. 

So we recently put ketamine on our trucks, and I have never used or seen it used for intubation. How many of you guys are currently using it and what circumstances are you grabbing for ketamine over etomidate.


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## systemet (Mar 6, 2015)

So we carry it.  We use it (1) to augment analgesia at 0.2 mg/kg; (2) for conscious sedation at 0.5 mg/kg, and (3) for RSI at 1.5 mg/kg * Although I would consider reducing the dose slightly if they're severely hypotensive or sympathetically-driven.

We pretty much use it for all our RSI. The opinion of our medical directors is that it's acceptable in closed head injury and status epilepticus, despite historical concerns. We used to have the option for fentanyl / midazolam and only use ketamine for hypotensive patients, but we've now been directed to use ketamine for pretty much everything, with the exception of perhaps a malignantly hypertensive patient.

When you use ketamine, you have to be aware that it doesn't have a traditional dose-response curve.  You tend to see a "staircase" effect, where you give a small dose and get analgesia (with a bit of altered mental status), then hit a state of dissociation, then hit an anesthetic level. It seems that you hit each plateau at a fairly arbitrary level.

Anecdotally:

* I have limited experience with using it for pain control in subdissociative dosing.

* I've used it a few times for conscious sedations in bad ortho injuries, including a pediatric femur fracture I discussed in one of the earlier threads.  If we're pacing we tend to use aliquots of fentanyl in preference (there's some theoretical concerns about negative inotropy -- ketamine has a complex pharmacology, it's an indirect sympathomimetic, but a negative inotrope), and for cardioversions, if they have a pressure we use fentanyl / midazolam. It's worked very well.

* For RSI, I love it.  Etomidate isn't an option here. It's nice to have an agent with a very rapid onset. I've seen a lot of RSI's go sideways, because someone gave fentanyl and midazolam, then didn't wait long enough for them to fully take effect. In practice, you can give the ketamine, wait 30-60 seconds, then push the succinylcholine.  Our current guidelines are to use fentanyl / midazolam for ongoing sedation (rocuronium is an option for paralysis, but rarely needed), if they are normotensive, or repeat ketamine if they remain (or become) hypotensive. I've talked with some physicians who feel that the effects of ketamine are insufficient in isolation, and that sometimes the addition of fentanyl offers better analgesia.

* We don't currently prophylacticaly treat with benzodiazepines to prevent emergence reactions.  This hasn't been a problem for me yet. I haven't heard of any bad situations from others, but this is no guarantee that this hasn't happened.

* We still use haloperidol / midazolam for chemical restraint. I'm curious about the use of ketamine, but have seen some fairly high intubation rates in the literature, e.g. 14/51 in http://www.ncbi.nlm.nih.gov/pubmed/25455046


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## PotatoMedic (Mar 7, 2015)

systemet said:


> So we carry it.  We use it (1) to augment analgesia at 0.2 mg/kg; (2) for conscious sedation at 0.5 mg/kg, and (3) for RSI at 1.5 mg/kg * Although I would consider reducing the dose slightly if they're severely hypotensive or sympathetically-driven.



Where I am doing some of my ride time for school we give 1-2mg/kg IV or 4-5mg/kg IM for RSI sedation.  And 5-10mg/kg IV for Excited Delirium.


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## systemet (Mar 7, 2015)

systemet said:


> * We still use haloperidol / midazolam for chemical restraint. I'm curious about the use of ketamine, but have seen some fairly high intubation rates in the literature, e.g. 14/51 in http://www.ncbi.nlm.nih.gov/pubmed/25455046



Also 8/36 here:

http://www.ncbi.nlm.nih.gov/pubmed/25153713


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## mfd229 (Mar 15, 2015)

Use Ketamine at least every other shift. We can use it for pain control or behavior control. We are currently doing a study on ketamine vs. haldol for combative patients. Ketamine is absolutely amazing in that aspect. Also used it about 2 months ago for a woman who fell out of a 3rd story window. Her wrist and elbow was dislocated, essentially her arm was backwards. Pushed ketamine to consciously sedate her and put her arm back in place so we could backboard her. No breathing issues whatsoever and we were able to put her arm in a neutral position with no pain. Works great! Love the drug. I have heard of some people having really bad trips coming out of it if you give them too much though.


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## chaz90 (Mar 18, 2015)

Hmm. Interesting stuff from everyone. I attended a great class on prehospital Ketamine at a conference last month taught by a Shock Trauma anesthesiologist, a large system medical director, and a MSP flight medic who seemed to be on his game. All three were quite in favor of rolling out Ketamine pre-hospitally for RSI, pain control, and chemical restraint. I don't have any real complaints about etomidate as an induction agent, but the pain control and restraint aspects for Ketamine are quite interesting. The anesthesiologist talked about how it was one of his favorite induction agents as well, so I'd certainly be willing to try it out.


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## chaz90 (Mar 18, 2015)

FireWA1 said:


> Where I am doing some of my ride time for school we give 1-2mg/kg IV or 4-5mg/kg IM for RSI sedation.  And 5-10mg/kg IV for Excited Delirium.



10 mg/kg IV???? That seems like an insane dose, even for excited delirium. An IV seems optimistic for a true excited delirium patient anyway, so perhaps IM makes more sense here.


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## PotatoMedic (Mar 18, 2015)

chaz90 said:


> 10 mg/kg IV???? That seems like an insane dose, even for excited delirium. An IV seems optimistic for a true excited delirium patient anyway, so perhaps IM makes more sense here.


Yeah that is a typo.  I ment to say IM.


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