Can we talk about these ketamine doses

[Nova1300]

Ugh, its been a while. This place still smells the same though. Like Cidex and red bull, and nicotine. Maybe Irish Spring too.

What does 2023 look like out there for those of you using ketamine in the field? what are the doses dictated by your protocols? What are the indications? Are you using it for psych purposes, analgesia, or intubation?

More importantly, do you like it? Or is it more trouble than its worth?

My local agencies are using HUGE doses, at least I consider them huge. Im curious as to the standard doses most folks are using.

 

[DesertMedic66]

Pain doses are 0.1-0.3mg/kg. RSI/sedation doses are 1-2mg/kg.

Indications are pain, RSI, sedation.

I personally love ketamine. Ketamine and Roc for RSI is usually my go to for RSI.

 

[Carlos Danger]

Pain doses are 0.1-0.3mg/kg. RSI/sedation doses are 1-2mg/kg.

Indications are pain, RSI, sedation.

I personally love ketamine. Ketamine and Roc for RSI is usually my go to for RSI.

What do you give with the ketamine for RSI?

 

[superGuitar]

My local agencies are using HUGE doses, at least I consider them huge. Im curious as to the standard doses most folks are using.

Care to give an example of what represents huge to you? My service is quite stingy on Ketamine use. 1.5 for induction and 0.3 for pain, and only after you exhausted nsaid and narcotics options. that's it. I sweet-talked OLMC into 0.5mg/kg on a long-distance transfer one time so I could dissociate a pretty sick Afib/RVR who was pulling everything off, but that was an exceptional occasion of getting permission.

 

[Tigger]

0.25mg/kg IV for pain, 0.5mg/kg IN/IM. In Colorado we are no longer allowed to sedate behavioral patients with it. When we were—5mg/kg IM was the most common dose.

2mg/kg for RSI induction, can use 0.5mg/kg doses to maintain sedation and analgesia.

It was the bee’s knees for sedation of the truly out of control. Sad we can no longer use it, I feel it is much safer than waiting for other agents to kick in.

I like it for treating injuries. It’s my go to for gnarly trauma. I have a coaching method and push it verrrrrry slowly with a good running line.

 

[DesertMedic66]

What do you give with the ketamine for RSI?

For the actual RSI we do have a choice between Ketamine, Etomidate, or Versed (some of it is protocol driven but it’s mostly left up to the crew) and then Roc or Succ (left up the to the crew to pick). Then for continued sedation/pain it’s ketamine, versed, fentanyl, or a mix (once again it’s up to the crew to decide).

 

[DesertMedic66]

Care to give an example of what represents huge to you? My service is quite stingy on Ketamine use. 1.5 for induction and 0.3 for pain, and only after you exhausted nsaid and narcotics options. that's it. I sweet-talked OLMC into 0.5mg/kg on a long-distance transfer one time so I could dissociate a pretty sick Afib/RVR who was pulling everything off, but that was an exceptional occasion of getting permission.

0.5mg/kg is usually considered a no go area because it falls in the zones of recreational and partially disassociated dose.

 

[Aprz]

pain 0.1-0.25 mg/kg
post intubation sedation 0.5-1 mg/kg
RSI 1-2 mg/kg
excited delirium/behavioral 4 mg/kg IM

Works as intended. I personally haven't had any major issues with it. I don't prefer it over drugs. I don't see it as any better or worse for things like RSI or pain management. I feel like the most common mistake I see with it is people giving too much.

@Carlos Danger I work at the same place. We most frequently carry Rocuronium and Succinylcholine. We sometimes have Vecuronium and have protocols for Nimbex too. By far the most preferred RSI combo is Rocuronium and Ketamine. I find a lot of people get uncomfortable with even trying a different combo. The most common way I see people approach it is they give 1 mg/kg Rocuronium estimating the patient's weight to the nearest 10 kg. I feel like everybody gives 100 mg Ketamine across the board for all adults, haha.

Rocuronium 0.6-1.2 mg/kg
Succinylcholine 1.5-2 mg/kg
Vecuronium 0.1 mg/kg
Nimbex 0.2 mg/kg

We also use 0.3 mg/kg Etomidate (up to 40 mg) or 0.05-0.3 mg/kg Midazolam (up to 10 mg in adults, 5 mg in pediatrics).

 

[Jn1232th]

My guidelines are 1-2mg/kg for intubation
0.5-1mg/kg for post sedation
0.1-0.25mg/kg for pain
5mg/kg for like combative/extrication purposes

 

[Akulahawk]

For ketamine, my "home" county currently uses 0.3mg/kg (max of 30mg) in 50-100 mL, infused over 10 minutes. May repeat once if pain remains, or returns to, moderate to severe. Bear in mind that most of our transports take less than 15 minutes. The pain protocol does specify Fentanyl 1 mcg/kg every 5 minutes (max single dose 100 mcg) with a cumulative max dose of 3 mcg/kg. It also allows for morphine (if fentanyl is unavailable) 0.1mg/kg (max dose 10 mg) every 5 minutes with a max total of 0.2mg/kg (20mg). Technically they also have acetaminophen (paracetamol for non US people) 1000 mg IV/IO over 15 min as a single dose but I haven't recently heard of any of my county's units giving it. Heck, my own ED doesn't give this stuff...

My ED relies primarily on Fentanyl, morphine, PO acetaminophen, PO ibuprofen, and PO Norco for pain control. I've been a fan of pain-dose ketamine for a while but I'm not a huge fan of giving it as a slow drip like this. 0.1mg/kg as an IVP dose followed by perhaps a 0.2mg/kg drip would probably be better... but I doubt they'd go for it. Ever.

 

[johnrsemt]

for Pain we use 50mg IN or 0.2mg/kg IV
for combative patients it is 4mg/kg IM.
We have only used it on 2 patients, 1 for pain 1 for combative. Worked great for both, glad I fought for it for 3 years.

Side note: the court cases in Boulder CO have started against the medics and officers that dosed the guy with Ketamine that died. I have only seen the results of the 1st day

 

[Tigger]

for Pain we use 50mg IN or 0.2mg/kg IV
for combative patients it is 4mg/kg IM.
We have only used it on 2 patients, 1 for pain 1 for combative. Worked great for both, glad I fought for it for 3 years.

Side note: the court cases in Boulder CO have started against the medics and officers that dosed the guy with Ketamine that died. I have only seen the results of the 1st day

*Aurora, CO

 

[johnrsemt]

Huh, news article I read said Boulder County, CO; but doesn't mean much