Ketamine

Revision as of 17:08, 11 January 2015 by Neil.m.young (talk | contribs) (nasal dose added)

Contraindications

Absolute

  1. <3 mo old
  2. Known or suspected schizophrenia, even if currently stable or controlled w/ meds

Relative

  1. Major procedures involving posterior pharynx (e.g. endoscopy)
    1. Typical minor ED oropharyngeal procedures are okay
  2. Airway instability (e.g. tracheal stenosis, tracheal surgery)
  3. Active pulmonary infection, including URI or asthma (unless for induction)
  4. CAD, HTN, CHF
  5. CNS masses, hydrocephalus (head trauma okay)
  6. Glaucoma/acute globe injury
  7. Thyroid disorder or on thyroid medication

Preparation

  1. Monitor
  2. BVM (ready)
  3. Suction
  4. Atropine
    1. Only recommended for pts w/ impaired ability to mobilize secretions
    2. 0.01 mg/kg IVP; min 0.1mg, max 0.5mg
  5. Versed
    1. Pretreatment is nonmandatory in both adults and children
    2. Consider 0.03mg/kg IVP if pt has unpleasant recovery reaction
  6. "Happy Place"

Administration

  • Given as a slow push bolus
  • IV prefered over IM (faster recovery, less emesis)
  • Nystagmus is seen as an effect of the medication

Procedural Sedation or Induction

IV

  1. Children: 1.5-2 mg/kg (over 30-60sec)
  2. Adults: 1 mg/kg (over 30-60sec)
  • Repeat dose 0.5-1 mg/kg q5-15 PRN

IM

  1. Children: 4-5 mg/kg [1]
  2. Adult: 4-5 mg/kg
  3. Repeat dose 2-4 mg/kg if sedation inadequate 10min after initial dose

Intranasal

  1. Children: 3-6 mg/kg[2]

Analgesia

IV

  1. Intermittent dosing at 0.1-0.5 mg/kg[3]

Ketamine "Dart" (IM) for Sedation

  1. May be an option for combative special needs patients; originally studied in pediatric pts with facial trauma in ED
  2. IM ketamine (3 mg/kg), midazolam (0.05 mg/kg), glycopyrrolate (0.005 mg/kg)[4]

Side Effects

  1. Airway misalignment requiring repositioning of head (occasional)
  2. Laryngospasm (0.3%)
    1. Only associated with unusually high IV doses
    2. Tx = BVM ventilation; intubation is rarely needed
  3. Apnea or respiratory depression (0.8%)
    1. Associated with rapid IV push
    2. Transient
  4. Hypersalivation (rare)
  5. Emesis, usually well into recovery (8.4%)
  6. Recovery agitation (mild in 6.3%, clinically important in 1.4%)
  7. Muscular hypertonicity and random, purposeless movements (common)
  8. Clonus, hiccupping, or short-lived nonallergic rash of face and neck
  9. Elevated Intracranial pressure
  10. May increase intraocular pressure

Discharge Criteria

  1. Return to pretreatment level of verbalization/awareness
  2. Return to pretreatment level of purposeful neuromuscular activity
  3. Do NOT have to wait until the pt can ambulate or tolerate PO

Intracranial pressure elevation

  • Cerebral perfusion pressure (CPP) was compromised only in the patients with pre-existing intracranial hypertension and obstruction to the flow of cerebral spinal fluid. This has, however, led to the persistent belief that ketamine is contraindicated in patients with traumatic head injuries. Studies done subsequently have shown, however, that the effects of ketamine on cerebral haemodynamics and ICP are in fact variable and depend on both the presence of additional anaesthetic agents and PaCO2 values.[5] Meta-analysis also suggests that Ketamine does not increase ICP and provides favorable hemodynamics.[6]

Neurologic Injury

  • Metaanalysis has shown that when ketamine is used in the presence of controlled ventilation, in conjunction with anaesthetics which reduce cerebral metabolism such as GABA receptor agonists, ICP is not increased.[7]

Pediatrics

  • In ventilated children with prior intracranial hypertension, ketamine decreased intracranial pressure (ICP) and prevented elevations during interventions without lowering blood pressure and CPP. [8]

Prehospital

  • In prehospital head trauma patients in Vietnam, no adverse effects on consciousness were observed when Ketamine was uses for analgesia[9]

Discharge Instructions

  1. NPO for 2hr
  2. No independent ambulation for 2hr

See Also

Source

  • Annals of EM. Clinical Practice Guideline for ED Ketamine Dissociative Sedation: 2011 Update
  • Chang LC, Raty SR, Ortiz J, Bailard NS, Mathew SJ. The Emerging Use of Ketamine for Anesthesia and Sedation in Traumatic Brain Injuries. CNS Neurosci Ther. 2013;19(6):390–395. doi:10.1111/cns.12077.
  • Sih K, Campbell SG, Tallon JM, Magee K, Zed PJ. Ketamine in Adult Emergency Medicine: Controversies and Recent Advances. Annals of Pharmacotherapy. 2011;45(12):1525–1534. doi:10.1345/aph.1Q370.

References

  1. ↑ Green S. et al. What is the optimal dose of intramuscular ketamine for pediatric sedation?. Acad Emerg Med. 1999 Jan;6(1):21-6
  2. ↑ Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.
  3. ↑ Morton NS. Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective. Paediatr Anaesth. 2008;18:25-29
  4. ↑ Pruitt JW, Goldwasser MS, Sabol SR, Prstojevich SJ. Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department. J Oral Maxillofac Surg. 1995 Jan;53(1):13-7.
  5. ↑ Filanovsky, Y., Philip Miller et al. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. CJEM 2010;12(2):154-7. PDF
  6. ↑ Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014. PubMed ID: 24859931
  7. ↑ Himmelseher S. et al. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005 Aug;101(2):524-34 PDF
  8. ↑ Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4(1):40–46.
  9. ↑ Tran, Kim. Quynh Nguyen, et al. A Comparison of Ketamin and Morphine Analgesia in Prehospital Trauma Care: A cluster randomized clinic trial in rural Quang Tri Province, Vietnam. Prehosp Emerg Care. 2014 Apr-Jun;18(2):257-64. doi: 10.3109/10903127.2013.851307
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