CA Ketamine Study

[NPO]

To be clear, my protocol isn't really less "complicated" it just feels like they're holding your hand a lot I guess? Idk if I'm really communicating what I'm trying to say correctly. Perhaps once it's out of trial phase it would resemble much more closely, what I think I would expect. I suppose standardizing things like the pain scale makes sense in the context of a trial.

 

[DesertMedic66]

It just seems more complicated than it needs to be. The actual protocol isn't that complicated, it's just the way it's spelled out, like saying anything over 5 on the pain scale, etc. Like why did that need to be defined? What's wrong with provider discretion?

Because we are using it for moderate/severe pain and not minor pain. Since it is a trial study drug that is not in the state approved medications for EMS the trial study has to be clearly defined as to what we are doing and how we are doing it. Once it becomes an approved medication then the protocol will become much more condensed and will allow us to use Ketamine for other means.

Let’s say we have a combative patient or a patient who does not fit in our criteria for the trial study, if we call the ED and the doc tells us to give this patient Ketamine we have to say no. There are no exceptions under any conditions.

 

[Aprz]

Handtevy.

Well, Handtevy is only for infants and adolescents, and I think Remi wasn't be specific to kids. For those of you not familiar with Handtevy, it's pretty simple. You estimate the weight in kg based of odd ages.

Age 1 = 10 kg
Age 3 = 15 kg
Age 5 = 20 kg
Age 7 = 25 kg
Age 9 = 30 kg

I also learned that the dose you'd give in cardiac arrest for Amiodarone and Epinephrine 1:10,000 are the same in mL, which is pretty handy.

 

[Tigger]

To be clear, my protocol isn't really less "complicated" it just feels like they're holding your hand a lot I guess? Idk if I'm really communicating what I'm trying to say correctly. Perhaps once it's out of trial phase it would resemble much more closely, what I think I would expect. I suppose standardizing things like the pain scale makes sense in the context of a trial.View attachment 4159

I've never seen a dosing like that before ever for pain. 1mg/kg is widely considered to be the "nightmare range."

 

[NPO]

Well, Handtevy is only for infants and adolescents, and I think Remi wasn't be specific to kids. For those of you not familiar with Handtevy, it's pretty simple. You estimate the weight in kg based of odd ages.

Age 1 = 10 kg
Age 3 = 15 kg
Age 5 = 20 kg
Age 7 = 25 kg
Age 9 = 30 kg

I also learned that the dose you'd give in cardiac arrest for Amiodarone and Epinephrine 1:10,000 are the same in mL, which is pretty handy.

Yes and no. While it was certainly created for pediatrics, it can be adopted for adults. The main idea is using ideal weights for calculations. But there is also a length based tape for your abnomally sized kids. When you buy into the Handtevy system you get a little booklet with doses for each age. You can use the book for adults too, but, and this was my point, for most of the medications we give in the field, you usually max out when you hit adults, so weight based doses apply much less. For the ones that do though, you can always consult the book.

For those unfamiliar, I suggest looking it up. Even if the system isnt for you or your agency, I have enjoyed learning from Dr. Antevy and his teaching style.

I've never seen a dosing like that before ever for pain. 1mg/kg is widely considered to be the "nightmare range."

I know. I'm not sure why we have it dosed that way. It's 1mg/kg* with the * being, avoid the danger zone. I'll usually go up or down from there to get the desired effect. But, I admittedly, have little experience with ketamine so far.

 

[Carlos Danger]

It really doesn't need to involve any calculations whatsoever. For a majority of the drugs we give in the field, it really can (and perhaps should) be as simply as: Xmg for a small adult, X.5mg for a medium size adult, and XXmg for a large adult. If you give it and it doesn't work, give more. Done.

Peds are different, though I would argue that dosing isn't as critical in peds as some make it out to be, either, for most drugs.

 

[Carlos Danger]

I've never seen a dosing like that before ever for pain. 1mg/kg is widely considered to be the "nightmare range."

I think for "severe pain refractory to narcotics" you might end up in that range sometimes.

But it makes much more sense to NOT have separate dosing ranges for "pain control" and "severe pain". Just broaden the initial dose range and remove the max dose, or at least make it much higher. Why say "give 0.1 mg/kg for pain, but not more than 30mg, unless they are in SEVERE PAIN, then give 1mg/kg"?

Instead, a good protocol would say "0.1 - 0.25 mg/kg up to a max dose of 2mg/kg". Let's keep it simple.

Or, as I said in a previous post, just get rid of the weight-based dosing. "Give 10-20mg boluses every 5 minutes until satisfactory analgesia is achieved. For very large patients who appear to be in severe pain or who have a history of chronic opioid use, may start with an initial bolus of 30mg". Or something along those lines.

 

[NPO]

I think for "severe pain refractory to narcotics" you might end up in that range sometimes.

But it makes much more sense to NOT have separate dosing ranges for "pain control" and "severe pain". Just broaden the initial dose range and remove the max dose, or at least make it much higher. Why say "give 0.1 mg/kg for pain, but not more than 30mg, unless they are in SEVERE PAIN, then give 1mg/kg"?

Instead, a good protocol would say "0.1 - 0.25 mg/kg up to a max dose of 2mg/kg". Let's keep it simple.

Or, as I said in a previous post, just get rid of the weight-based dosing. "Give 10-20mg boluses every 5 minutes until satisfactory analgesia is achieved. For very large patients who appear to be in severe pain or who have a history of chronic opioid use, may start with an initial bolus of 30mg". Or something along those lines.

I don't disagree. I mentioned it to the paramedic who assisted in writing the protocol and he said when he wrote it, he specifically put in there too avoid going into near 100mg, but I forget how he specifically worded it.

 

[Uclabruin103]

I've never seen or administered ketamine, but waiting five minutes just to give it, plus another three or four to set it up... I'm way more likely to give fentanyl. And I'm all for new drugs.

Is it that much better than fentanyl?

 

[RocketMedic]

It is often wayyyy better than fentanyl

 

[Carlos Danger]

I've never seen or administered ketamine, but waiting five minutes just to give it, plus another three or four to set it up... I'm way more likely to give fentanyl. And I'm all for new drugs.

Is it that much better than fentanyl?

Ketamine isn't better than fentanyl, it's different. Saying one is better than the other is like saying that esmolol is better than nicardipine, or a pickup is better than a minivan. For what scenario? What are you using them for? They can do some of the same things but they aren't interchangeable.

Ketamine has enjoyed a well-deserved resurgence in the past handful of years, and there are times that it's the best option. But opioids are still a better choice in most cases of non-complicated, acute nociceptive pain. They are better anxiolytics and have sympatholytic and muscle relaxant properties, among others.

What do you mean "waiting five minutes to give it, plus another three or four to set it up"?

 

[Uclabruin103]

That you have to give it over five minutes in a drip for the full dose and it sounds like it's a very conservative dose at that. How about for sedation for agitation, versed or ketamine (what IM dose is typical to be effective)

 

[DesertMedic66]

That you have to give it over five minutes in a drip for the full dose and it sounds like it's a very conservative dose at that. How about for sedation for agitation, versed or ketamine (what IM dose is typical to be effective)

The dose of 0.3mg/kg is actually a pretty decent dose and is in the normal range for low dose or a subdissociative dose. Depending where you look those doses are 0.1mg/kg to 0.5mg/kg.

The IM dose for sedation is going to be different because in that case it is not being used for pain control. The trial study is limited to only pain. Under no circumstances are we allowed to use it for any other condition under anyone’s orders.

 

[CALEMT]

The trial study is limited to only pain.

And even then once it’s approved I doubt it’ll be approved for sedation.

 

[RocketMedic]

Something's better than nothing.

IMO, the best approach to pain is a multifaceted one. A moderate dose of opiates to block mu receptors, ketamine to disassociate and keep those mu receptors blocked, and an NSAID like Tylenol to impede inflammation.