Ketamine for Pain Management: Writing an article, your opinions?

[RocketMedic]

Had a case a while back that begged for a case study, so I wrote an article about it. Trying to get it approved by management, but thought I'd share it with y'all for review too.

 

[captaindepth]

Overall I thought it was a pretty good read and not a bad sales pitch for Ketamine as an analgesic. The initial pain management protocols seemed very limited, I guess different places can have different standing orders for pain management but if somewhere has a such a limited opioid analgesic protocol I have a hard time believing they would add Ketamine to their standing orders. I have always had good experience with Fentanyl and Morphine for isolated orthopedic injuries and been able to safely manage pain and discomfort (I.M.E.). I thought the hammer/nail/screwdriver analogy was kind of loose and did not really tie the concepts together. Also I noticed this "he reports that his pain has returned, going from a 0/10 to a 6/10 after approximately 12 minutes; and you administer another dose of 10mg of fentanyl in 10mL of saline solution. Once again, his pain resolves entirely" I'm assuming the 10mg of Fentanyl should be Ketamine. I would think a section for potential side effects for Ketamine would be warranted as well in this write up, although rare some of the side effects are certainly important to be aware of and prepared for.

 

[SpecialK]

Ketamine is absolutely hands down the most amazing analgesic ever. If you look back in history for years it was entonox and morphine (or methoxyflurane and morphine) and well, that was it. Thankfully, times have changed.

Have a look for some research done by Ambulance Victoria; they did some RCTs looking a ketamine and morphine v only morphine.

Why not see if you can get entonox or methoxyflurane too if you don't already have it. Both are marvellous but if you can only have one, MOF is probably clinically a bit better because it has less contraindications.

 

[EpiEMS]

Just a couple of thoughts:

- In the considerations paragraph, I think you hit the same point twice, which is fine, just something to be aware of. The construction of this sentence is a bit awkward: "
- In the initial response paragraph, I would strike the parenthetical comment "(for example, most of California)". While I think it is probably true, I don't think it is necessary to call it out (nor am I aware of a way to substantiate it).

Everything else looks pretty good!

I would love to add some thoughts like @SpecialK suggested, e.g. about other mechanisms by which we can reduce pain/discomfort - as a BLS provider, I'd love to have a green whistle!

 

[Carlos Danger]

Did the call actually go like this? Little relief from fentanyl but great relief from a very small dose of ketamine?

 

[SpecialK]

Did the call actually go like this? Little relief from fentanyl but great relief from a very small dose of ketamine?

I was wondering about that too as this hasn't been my experience. Also, 100 mcg of fentanyl is really a bit soon to stop and decide to give some ketamine especially when they concurrently aren't getting an inhaled pain relief too.

I'd have considered giving him some ketamine if methoxyflurane, oral tramadol and closer to 200 mcg of fentanyl in say 50 mcg aliquots hadn't worked.

Truth be told, I'd much rather have been able to give him a nerve block rather than hop this poor kid up off the planet on a combination of painkillers. Hmm, hopefully soon.

Ketamine is great stuff but perhaps a case with higher value would be somebody with a shattered femur needing realignment or something?

 

[RocketMedic]

It did go quite well- a loading dose of fentanyl didn't do much, but small doses of ketamine went a very long way without any side effects I could see. No emergence reaction either.

A green whistle or nerve block would be quite useful.

 

[MonkeyArrow]

Nerve blocks, guys, really? Nerve blocks. Things done by specialized anesthesiologists with years of training you want to do in the field? I haven't ever seen a nerve block done even in the ER except for minor things like finder dislocations. Pain management is not as big an issue as y'all are making it out to be to need pain blocks pre-hospitally.

 

[RocketMedic]

Our PA did a few in the Army. Helped me out with my finger

 

[EpiEMS]

Our PA did a few in the Army. Helped me out with my finger

Does one need ultrasound (or similar) guidance to do one?

 

[Brandon O]

Does one need ultrasound (or similar) guidance to do one?

Depends on the block. Fingers (usually a ring block) are easy. Some fancy stuff like femorals use the 'sound. (Not real lingo.)

 

[RocKetamine]

Forgot to put in the inevitable freak out from the ED because "the patient requires one-on-one care now!!!"

 

[RocketMedic]

Forgot to put in the inevitable freak out from the ED because "the patient requires one-on-one care now!!!"

MH Woodlands was cool with it.

 

[TXmed]

"Many EMS services that carry ketamine carry it in large vials- 500mg in 5mL, with an effective concentration of 100mg to 1mL. This means that we need to be aware of what syringe we are using and dilute the ketamine to effect. Three safe methods of administering ketamine in this high concentration are to use a 1mL syringe, use a 10mL syringe with 1mL of ketamine and nine of saline, or even mix one milligram in a 100mL bag of normal saline and have a 1mL/mg concentration."

I believe you meant to say one ML of ketamine.

I thought it was well written and a perfect example of why I personally believe ketamine is becoming a standard of care for pain management (if used properly). I also think aggressive use on pain that you suspect may not be controlled easily with opioids is a great strategy.

Health care in general is pushing more for "opioid light" treatment of pain and ketamine (along with IV Tylenol) is what will help you do that.

Not that anyone needs anymore podcasts to listen to but I attached one just because its one of my favorites and its a about ketamine.
https://www.smacc.net.au/2015/12/ke...ly-for-all-its-indications-by-reuben-strayer/


Good job @RocketMedic

 

[SpecialK]

Nerve blocks, guys, really? Nerve blocks. Things done by specialized anesthesiologists with years of training you want to do in the field? I haven't ever seen a nerve block done even in the ER except for minor things like finder dislocations. Pain management is not as big an issue as y'all are making it out to be to need pain blocks pre-hospitally.

Oh, rubbish. Ring blocks came out two CPGs ago and there is the talk of more specialised blocks coming, particularly, but not exclusively, with ultrasound. The ED seems to like them too; for things like hands or wrists or ankles or such; I've even seen somebody have their dislocated shoulder put back in with a block and good huffings of entonox and I've heard of the HEMS Docs doing them for people with # femurs and whatnot.

Obviously not something to be done with every pt (which brings up the thorny issue of maintenance) but a selected few additional ones wouldn't be the end of the world and would be very helpful for certain patients like this one.

How have you found intravenous paracetamol? Not something I've seen.

 

[Carlos Danger]

Oh, rubbish. Ring blocks came out two CPGs ago and there is the talk of more specialised blocks coming, particularly, but not exclusively, with ultrasound. The ED seems to like them too; for things like hands or wrists or ankles or such; I've even seen somebody have their dislocated shoulder put back in with a block and good huffings of entonox and I've heard of the HEMS Docs doing them for people with # femurs and whatnot.

Obviously not something to be done with every pt (which brings up the thorny issue of maintenance) but a selected few additional ones wouldn't be the end of the world and would be very helpful for certain patients like this one.

Well, ring blocks aren't really nerve blocks. You are just infiltrating the skin and all you get is correspondingly superficial analgesia for things like burns and very minor, superficial procedures. US-guided blocks are a whole other animal.

I do regional anesthesia as a CRNA and I am also a paramedic, and I can tell you with certainty that a US guided block is a FAR more complex procedure than anything else done in the field. There is much more to it than using US for abdominal scans or even vascular access. In order to do them safely and consistently, one would have to devote far more time and resources to learning them than a huge majority of paramedics will ever be able to. It is not a skill that you gain proficiency at just by having someone show you how to do it once and then doing one every now and then like we do with most things in EMS. You might have one work well sometimes, but you would certainly have a high rate of block failures and with some blocks, very serious complications are quite possible.

Relatively few EM physicians even do them, for these exact reasons. Those that do are mostly docs that did a regional anesthesia elective as part of their residency AND have a special interest in regional anesthesia.

Nerve blocks are also time consuming to place. Positioning is important. Sterility is desirable. Patients need to be still. Many or most require some sedation. They also can take a fair amount of time just to take effect, depending on the local and the specific block. You are not going to "just pop a block in" while cruising down the road in an ambulance. Even with everything going well, you can easily spend 10, 15, even 20 minutes on scene placing a block and then it could take nearly that long again before the block takes full effect.

I am not at all opposed to paramedics (or anyone else) learning regional anesthesia, but I am very opposed to it being done half-assed the way that most skills in EMS are taught. Because trust me, you WILL hurt a patient doing this stuff without really knowing what you are doing.

I think we are getting way ahead of ourselves and making analgesia a lot more complex than it needs to be. Give some fentanyl, give some ketamine, if you need to give some versed. It's safe and easy and works perfectly well in 99.99% of cases.

 

[MonkeyArrow]

Oh, rubbish. Ring blocks came out two CPGs ago and there is the talk of more specialised blocks coming, particularly, but not exclusively, with ultrasound. The ED seems to like them too; for things like hands or wrists or ankles or such; I've even seen somebody have their dislocated shoulder put back in with a block and good huffings of entonox and I've heard of the HEMS Docs doing them for people with # femurs and whatnot.

Obviously not something to be done with every pt (which brings up the thorny issue of maintenance) but a selected few additional ones wouldn't be the end of the world and would be very helpful for certain patients like this one.

How have you found intravenous paracetamol? Not something I've seen.

That's all anecdotal evidence. Sure, it can be used in select patients. But is it something that EMS providers should be providing, no. All of the fractures that you listed can be cared for/reduced perfectly fine by other means (IV analgesia/sedation) 99% of the time. I don't know about you, but I'm not reducing fractures in the field with any regularity. Even in the ED, guess what happens that 1% of the time. You pick up the phone and call someone with more training and expertise than you, whether it be the arthropod or anesthesiologist to manage the case.

And I don't use IV paracetamol.

 

[Eden]

Nice read, ketamine for pain management is excellent and safe. Very effective with an opiate and works well without one too.

 

[Akulahawk]

I also caught this: "or even mix one milligram in a 100mL bag of normal saline and have a 1mL/mg concentration" and thought you truly meant to write it as "or even mix one milliliter, at 100mg/mL concentration, in a 100mL bag of normal saline and have a 1mL/mg concentration."

Otherwise I thought the article, clearly not a research article, was well done and should hopefully be at least somewhat anecdotally persuasive to some Medical Directors to allow ketamine on ALS ambulances. My experience with ketamine is very similar to yours: low dose at around 0.2mg/kg works pretty well for pain control without inducing sedation. My only problem with it is it doesn't magically cure pain in patients that are actively seeking an opiate such as dilaudid...

 

[jbiedebach]

There is a lot of evidence for the additive effects of ketamine + fentanyl. We used to dose it like you described (typically ketamine first, followed by fentanyl). However we had some suboptimal experiences with patients reporting a "heavy" or "drunk" feeling after Ketamine slow IV push (10-20mg). We set up a little test and the combination we had the best results with was 20mg Ketamine + 50mcg Fentanyl in a 100ml saline bag run in over 5 min, titrate to effect. Our patient really liked the combination, the dilution and drip vs push seemed to help avoid a lot of the Ketamine side effects and patients report a much better experience as the combo wears off.


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