• Rapid Reviews: Ketamine

    by Alan Batt. Last modified: 27/05/14

    ketamine

    Overview

    • Non-opioid; analgesic and dissociative properties
    • Dissociation is not dose-related, it is either present or absent
    • Additional doses do not enhance or deepen sedation
    • Induces the analgesic and dissociative state within 60 seconds after a single IV dose and within 3 to 5 minutes for an IM dose. This sedation lasts approximately 10 to 15 minutes for IV doses and 20 to 30 minutes for IM doses.
    • Exerts sympathomimetic effects producing mild increases in blood pressure, heart rate, cardiac output, and myocardial oxygen consumption
    • Shown to alleviate bronchospastic activity and reduce airway resistance in patients with pulmonary disease
    • May have a direct neuroprotective role

    Useful Review Articles

     
    Bredmose PP1, Lockey DJ, Grier G, Watts B, Davies G. Pre-hospital use of ketamine for analgesia and procedural sedation. Emerg Med J. 2009 Jan;26(1):62-4. PMID: 19104109.
    • Retrospective trauma review
    • 1220 patients received ketamine over a 5 year period
    • IV ketamine the preferred analgesia on scene by London HEMS doctors
    • No cases where airway manoeuvres were required post administration; no significant complications
    • Not all side effects documented
     
    Jennings PA1, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, Masci K. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012 Jun;59(6):497-503. PMID: 22243959.
    • Prospective, randomized, controlled, open-label study (unblinded due to safety reasons)
    • 136 patients enrolled, randomly assigned to morphine & ketamine or morphine alone
    • Ketamine & morphine group had larger decrease in pain score on arrival at ED; quicker reduction of pain
    • Ketamine group had larger incidence of mild adverse effects, mainly emergence phenomenon, disorientation, altered LOC, sympathetic changes (hypertension, tachycardia etc.)
    • Methoxyflurane given to most patients prior to IV analgesia intervention
    • No clinically significant differences in vital signs after enrolment
     
    Tran KP, Nguyen Q, Truong XN, Le V, Le VP, Mai N, Husum H, Losvik OK. A comparison of ketamine and morphine analgesia in prehospital trauma care: a cluster randomized clinical trial in rural Quang Tri province, Vietnam. Prehosp Emerg Care. 2014 Apr-Jun;18(2):257-64. PMID: 24400915.
    • Prospective, cluster-randomized design (unblinded)
    • 169 trauma patients were treated outside hospital settings with ketamine, while 139 patients were treated with morphine.
    • Patient experience of pain not documented
    • Five patients in the ketamine group and 10 patients in the morphine group experienced negative treatment effects, defined as more pain on admission than before analgesic treatment
    • Nausea and vomiting were observed in 27 patients (19%) in the morphine group and 8 patients in the ketamine group (5%)
    • Three patients in the ketamine group had excessive salivation, and 19 patients (11%) demonstrated agitation.
     
    Svenson JE1, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007 Oct;25(8):977-80. PMID: 17920984.
    • Retrospective study of all patients transported by a regional aeromedical program
    • 40 patients received ketamine over 3 years
    • All had already received large doses of narcotics without relief
    • Most patients only required 1 dose of ketamine to achieve adequate pain relief
    • No patients in any subset (burns, trauma, cardiac) suffered hypotension post administration of ketamine
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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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