Ketamine

[EMT11KDL]

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.

 

[systemet]

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

 

[PotatoMedic]

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.

 

[systemet]

* 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

 

[mfd229]

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.

 

[chaz90]

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.

 

[chaz90]

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.

 

[PotatoMedic]

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.