Prehospital use of Ketamine
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MagicTyler
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Not pre hospital, but I've saw a doc use it in the ED for a trauma with borderline pressures for RSI. Ketamine and succs.
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There's a lot of talk right now on us getting it (just talk so far). Our local HEMS uses it, but I don't have a lot of experience with it myself
the_negro_puppy
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Out Intensive care paramedics carry it and use it for:
- Adjunct to morphine (0.1-0.2 mg/kg) in patients with severe traumatic pain associated with:
- Fracture reduction and splinting
-Multiple or significant fractures requiring facilitated extrication.
Dose- IV 10mg-20mg every 2-3 mins max dose 1mg per kg
I have not seen it used
usafmedic45
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Wonderful stuff. We have it on the air ambulance. It's my first line drug for intubation of crashing asthmatics, hypotensive trauma patients and now there is some evidence that it has neuroprotective effects and might be beneficial in head trauma. The old advice about avoiding it in head trauma to avoid increases in ICP appears to have no basis in evidence.
It is also ideal for pain control in severe burns and long bone fractures that are not controlled by morphine or fentanyl.
It is also ideal for pain control in severe burns and long bone fractures that are not controlled by morphine or fentanyl.
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When you use it for RSI do you use it with sux vec or roc as your paralytic if sux is there a worry about useing the two together and causing increased ICP or is all of that unfounded
Thanks this is helpful
usafmedic45
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It's pretty much unfounded.
As for using it with sux or vec, it depends. Some patients you don't need to give a paralytic with but in almost every cases one is given along with the ketamine. Also you should always give a benzodiazepine along with ketamine to avoid the emergence reaction that is well known to be the primary problem with use of ketamine.
Smash
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I'll second usaf, ketamine is a brilliant drug, extremely effective and very versatile. Just make sure you don't push it too fast in big doses, or you might get a fright!
usafmedic45
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Ativan is my benzo of choice for most things, but mostly due to my having more experience with it than anything else.
Ketamine was introduced for our Intensive Care Paramedcs in 2007 and it's hands down the best bloody thing out there, absolutely brilliant stuff!
We are using it at low doses for analgesia (preferably in combination with morphine but not an absolute requirement) and for induction prior to RSI. For RSI we use it in combination with fentanyl, suxamethonium and vecuronium.
It's great stuff for burns, MSK pain/trauma and severe pain not responding to morphine which is primarily why we introduced it however it also posessed bronchodialatory effects and doesn't cause negative respiratory and circulatory problems like benzos and morphine can which makes it particularly useful in asthmatics and hypotensive trauma patients. While our Intensive Care Paramedics have the option of using morphine+midazolam that has really fallen out of fashion now that everybody has ketamine, midazolam is not an analgesic and provides no pain-relieving properties whereas ketamine has profound analgesic effect at low doses.
As for the nightmares/hallucinations/emergence syndrome everybody is quick to point out I have not seen it in any of the patients ketamine has been administered to which include burns, NOFs and some bloke with a nunngered femur but I've seen one patient reckon his name was "banana" post-ketamine so you might want to keep some ice cream handy for an impromptu desert
Oh, don't worry about increased intracranial pressure with ketamine, there are some studies out there I have read but am too lazy to look up which concluded it's like that whole don't give Grandpa with COPD oxygen thing; I know one was from the Israeli Defence Force.
The only problem with using ketamine for analgesia is it's awful bloody wasteful; 200mg/2ml into a 100ml pack of D5 to make 2mg/ml means that you end up throwing out most of what was in the vial.
We are using it at low doses for analgesia (preferably in combination with morphine but not an absolute requirement) and for induction prior to RSI. For RSI we use it in combination with fentanyl, suxamethonium and vecuronium.
It's great stuff for burns, MSK pain/trauma and severe pain not responding to morphine which is primarily why we introduced it however it also posessed bronchodialatory effects and doesn't cause negative respiratory and circulatory problems like benzos and morphine can which makes it particularly useful in asthmatics and hypotensive trauma patients. While our Intensive Care Paramedics have the option of using morphine+midazolam that has really fallen out of fashion now that everybody has ketamine, midazolam is not an analgesic and provides no pain-relieving properties whereas ketamine has profound analgesic effect at low doses.
As for the nightmares/hallucinations/emergence syndrome everybody is quick to point out I have not seen it in any of the patients ketamine has been administered to which include burns, NOFs and some bloke with a nunngered femur but I've seen one patient reckon his name was "banana" post-ketamine so you might want to keep some ice cream handy for an impromptu desert
Oh, don't worry about increased intracranial pressure with ketamine, there are some studies out there I have read but am too lazy to look up which concluded it's like that whole don't give Grandpa with COPD oxygen thing; I know one was from the Israeli Defence Force.
The only problem with using ketamine for analgesia is it's awful bloody wasteful; 200mg/2ml into a 100ml pack of D5 to make 2mg/ml means that you end up throwing out most of what was in the vial.
the_negro_puppy
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usafmedic45
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Is the stuff used as a party drug down there like it is used in some circles up here? If it is, that would explain how Brown is getting his hands on it.
Is the stuff used as a party drug down there like it is used in some circles up here? If it is, that would explain how Brown is getting his hands on it.
Yes it is
I never did drugs, well, not personally, gave them to other people tho, but they all came out the green pack
Yes
Ketamine for use with asthmatics is given as an induction agent to provide anaesthesia for intubation, so yes we are utilising the hypnotic/amnestic properties of it for exactly that reason, the bronchodialatory effect is just a nice add on.
Induction dosage is 1.5mg/kg here but I have seen anything from 1-3mg/kg in the literature/textbooks.
Ketamine has no sedating property on the central nervous system like morphine or a benzo per-se rather it is a disassociative anaesthetic that (for want of a better description) acts as a NMDA blocker and "disconnects" the limbic system from the higher brain centres (I think the hypothalmus) to produce a state of disassociation rather than one of traditional sedation or GABA-blockade anaesthesia.
usafmedic45
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Nah, it's primarily the bronchdilatory effect (the catecholamine release). The dose is the same as for any other anesthesia induction with ketamine.
Actually, speaking from experience with it, the primary reason for its use by medical professionals is its bronchodilatory effects. There's no hypnotic/amnestic effect since it's an anesthetic not a sedative. Any other benefit normally associated with its use are cancelled out by the fact that it's chased with paralytic in most cases.
Then it does not have a hypnotic/amnestic effect. Either it's a dissociative anesthesia or it's a hypnotic/amnestic (think Versed).
I have never personally used Ketamine as an analgesic or anaesthetic (saw my college roommate get dosed for a dislocation reduction in the E.R. though, that was hilarious) and only used etomidate once for RSI purposes during my hospital clinicals, but I have heard that Ketamine is preferable to Etomidate in anesthesia and RSI applications because of less adrenal suppression, especially in prolonged infusion rates. Is there a possibility that Ketamine and Fentanyl will take the place of Etomidate and Morphine in the prehospital field?
Smash
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I think there is. The real danger of etomidate in the critically unwell patient hasn't been fully elucidated. There is no doubt that even a single dose causes a suppresion of the adreno-corticoid axis, but what isn't clear is whether this actually has any clinical effect in the long run. I think there is still a lot of research to be done before we throw away etomidate, however in the meantime, given the choice, I would almost always pick ketamine as my first line agent.
I don't think that it will replace morphine. Morphine is mostly effective, relatively safe and everyone is very comfortable with it due to it's long history. It will certainly augment it however, as it really is a wonderful drug for analgesia in certain settings.
i agree completely that fent will not replace MS however due to its quick action and short halflife i think it will and should be used more. However to take away MS completely is to take away a tool and a great tool at that.