How to use ketamine fearlessly for all its indications smacc 2015 no builds

Ketamine: How to Use it Fearlessly For All its Indications

reuben j. strayer @emupdates

Ketamine: How to Use it Fearlessly For All its Indications

reuben j. strayer @emupdates

no disclosures / conflicts

the effects of ketamine on the body

hypertension tachycardia

bronchodilation

the effects of ketamine on the brain

the effects of ketamine on the brain

ketamine brain continuum

analgesia

recreational

partially dissociated

dissociated

10 mg

30 mg

50 mg

100 mg

procomplete analgesia, sedation, amnesia airway reflexes maintained cardiorespiratory tone augmented

rapid onset, predictable duration can be used intramuscularly unmatched margin of safety

conhypertension, tachycardia hypertonicity hypersalivation no reversal agent psychiatric distress

ketamine for procedural sedation

Brown 2008 Chong 2013

ketamine for procedural sedation

anticipateketamine brain continuum - be careful with small doses

treat

preventpre-induction comfort pre-induction coaching

psychiatric distress is not a reason not to use ketamine

vs. ketofol Green 2011

ketamine for RSI

partial dissociation and emergence distress not a concern

vs etomidate

can be used in all patients where increase in HR and BP is acceptable

take advantage of the flat part of the brain continuum: dose big

unless obtunded and very hypotensive

the contraindication myths have been debunked increased ICP increased IOP psychiatric disease

Chang 2013 Filanovsky 2010

Himmelseher 2005 Sehdev 2006

Halstead 2012 Drayna 2011

Le Cong 2010

excellent for all hypotensive patients, including trauma

optimal for patients being intubated for asthma or COPD

ketamine for post-intubation sedation

push ketamine, not vecuronium

severe oxygenation or ventilation deficit? NIV, KSIyes

no

yes preoxygenate

obtunded, no blood pressure? NoSIyesresuscitate

time, cooperation?

no

KSI double setup

yes

awake intubation

high risk to vomit? yesRSI

double setup

no

yes

glycopyrrolate lidocaine

head elevation NG tube LMA ventilation if needed

high concern for difficult laryngoscopy? RSIno

no

ready with plan B, C, D

apneic?

yes

RSI

tolerates optimal preoxygenation? DSInono

abdominal migraine chronic ischemic pain atypical odontalgia phantom pain postherpetic neuralgia post-stroke pain spinal injury pain TMJ joint arthralgia intractable headache

ketamine for analgesia

ketamine is a powerful analgesic - 0.15 mg/kg

when opioids are not effective

when opioids are not desired

daily opioid users with chronic pain and some other reason to be in the ED

Bell 2009 Ahern 2013 Fine 1999

Gharaei 2012 Jennings 2011 Richards 2012 Zempsky 2010 Beaudoin 2014

Ding 2014

low back pain chronic pancreatitis fibromyalgia myofascial pain syndrome complex regional pain syndrome sickle cell opioid withdrawal neuropathic pain cyclic vomiting gastroparesis

ketamine for analgesia

ketamine is a powerful analgesic - 0.15 mg/kg

when opioids are not effective

when opioids are not desired

daily opioid users with chronic pain and some other reason to be in the ED

recovered opioid addicts with acute pain

marginal blood pressure or breathing

bolus vs. drip

Bell 2009 Ahern 2013 Fine 1999

Gharaei 2012 Jennings 2011 Richards 2012 Zempsky 2010 Beaudoin 2014

Ding 2014

20 mg over 10 minutes, then 20 mg/hour titrated to effect

not PSA - no monitoring required

ketamine for asthma

Denmark 2006 Goyal 2013

Heshmati 2003 Shlamovitz 2011

ketamine for tranquilization

speed, safety, reliability, IM

increases in HR and BP less than uncontrolled thrashing rage

this is procedural sedation - treat as such

ketamine 500 mg IM x 1

ACEP 2009 Roberts 2001 Burnett 2012

ketamine brain continuum

analgesia

recreational

partially dissociated

dissociated

10 mg

200 mg

?

ketamine for suicidality?

use ketamine fearlessly

procedural sedationairway managementanalgesiaasthmatranquilization

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