Looking for help with ketamine in the field. My service is looking into the use of ketamine on the ambulance. Any help will be greatly appreciated.

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Interested in the evidence of need???  Thanks.

Just curious what is our service looking at using ketamine for. I have only ever observed it being used for conscious sedation in fracture reduction but this was in the hospital setting. Does ketamine have any notable benefits over other medication.

There is good evidence that small ketamine doses cut opiod use while helping to maintain the patient's airway. It doesn't cause hypotension and the patient continue to breath.

Here are a few a college gave me:

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The service I work for uses it as an alternative pain management drug, or as a sedative.  For pain management it is preferred over the standard meds (dilaudid, morphine, etc) but only in patients where hypotension is present or is likely to result; however, ketamine's use in pain management in such instances is not so much for treating the pain, instead we are using its effect as a dissociative hypnotic to sedate the patient.  A prime example is we had a bad head-on MVA where our pt had an obvious femur fracture and was hypotensive.  The extrication took upwards of 45-60 minutes due to the extensive damage, and we came to a tipping point where no further progress could be made and there wasn't enough room to splint the leg .  At that point we needed to just get him out of the car.  We administered ketamine to sedate him in anticipation of the excrutiating pain he would have otherwise felt when removing him.  The ketamine worked very well and the patient had a good outcome. 

Additionally, our medical director approved its use as an induction agent for RSI due to the nation-wide medication shortages we've been experiencing.  We had issues getting our hands on versed, and we are not approvd to use etomidate, so our options were limited.  I've used ketamine once or twice in conjunction with succinylcholine for RSI and it seemed to work pretty well.  The major benefit of ketamine is that it doesn't cause hypotension, and in some cases may actually slightly increase respirations.  It also helps that it can be given IV, IM, and IN.

I just instituted Ketamine and it has been met with great interest, after the initial hurdle of learning a new and unique medication.  We have protocols for full dose with major trauma, RSI induction, and excited delirium.  Low-moderate dose for agitation to facilitate CPAP and avoid intubation (CHF, COPD, status asthmaticus).  Low titrated dose for narcotic-refractory analgesia.  Pros: Multiple routes (IV, IM, nasal), multiple applications, no hypotension, no respiratory depression, essentially you are not able to give a fatal dose, applicable to all ages (except infants, little research), inexpensive.  Cons: Requires specific training/education and review with EMS and especially local EDs if they are not used to using it, no antidote/reversal, disinhibition even low dose takes a little getting used to (almost every pt drops a few colorful adjectives during treatment or while coming out of it).  Had to field a couple of phone calls during the first month or so, from both crews and receiving EDs.  Feedback on cases is essential for the EMS and ED staff alike.  Video examples of its use helps prepare the staff for the dissociative state, what is looks like, how pts will act.  Overall we have had some fantastic outcomes, including personal testimony by a local ED staff member with a dislocated shoulder requiring extrication and a thoughtful dose for a terminal patient on high-dose narcotics with refractory pain during her last transport to hospice.  This is my new favorite critical care medication; however, it does take some education, consideration and appropriate application.  I have used it more in the past couple of months than in the previous decade combined.  I expect it to replace our Etomidate shortly.         

We replaced our Etomidate with it about 3 months ago. And with a little benzo, (.5 ativan) I have been told the resurgence issues (when they are coming out of the Ketamine cloud) are mitigated.

Considering the number of services that seem to be adding ketamine, I hope to see some prospective studies (but I'm not confident that the average medical director is that proactive).  It would also be nice to see some data for head injuries so that the increased ICP bogeyman can either be put to rest or be confirmed.  Considering that EMS has adopted many treatment in the past that have been debunked, I'm not too keen on anything being added without some evidence to support it (even if I do think it could be useful).

Scott: See my first posting, there are some studies there.

Hi Guys. I have been using Ketamine for over 9 years myself and have observed it being used by pre-hospital Doctors in the UK, previous to that. It is a safe drug to use, but when introduced does create some trepidation amongst pre-hospital providers and ED Doctors. A lot of the objections raised are common when introducing any new medication or proceedure which has a lot of conjecture or rumor attached to it. Most of these fears are not based on fact or evidence. Scott Lancaster has provided some great links to support its introduction. To add to this this drug has been used in Europe for decades ( Mostly by Physician led systems) but also has been used in the third world for even longer. In fact it is commonly used for surgical proceedures were the patient can't be intubated. The benefit and safety profile of the drug is pretty high. It doesn't lower blood pressure or knock off airway reflexes, it can be tailored to what effect is required and can be given in a variety of ways. The emergence reaction can be an issue but as already stated a small dose of a benzo will blunt this. The other issue is laryngo-spasm, which seems to be an issue in much larger doses. I personally have used it to facilitate intubation, sedate close head injured patients and successfully treat pain alone or in conjunction with other agents. It has been so effective with a scald/ burn patient that they had to be reminded that they had an injury to their whole arm for a pain score. I would recommend everyone look into its introduction as it has so many uses and benefits over other agents. It is one of the most useful and flexible agents I carry and can really make the difference in managing so many patients. I have included a link to our Clinical Management Guidelines to show how we use Ketamine.esa.act.gov.au/actas-clinical-guidelines/index.html

Take care, Pete H.

 

I did.  Most of the prehospital ketamine studies were not done in the US or were in non-ground settings or included physicians as part of the prehospital team.  Don't get me wrong, ketamine sounds like a great drug.  And I definitely appreciate its versatility, but it does seem to have its downsides like any other drug.  EMS has tried to extrapolate the outcome from procedures or drugs used in hospital and/or performed by physicians in the past with mixed results.  Just because someone with more experience and more indepth training and education has good success (e.g. physicians or, hell, even MICA paramedics in Australia), doesn't mean that US paramedics will see similar success.  

Scott Lancaster said:

Scott: See my first posting, there are some studies there.

Perhaps. It has also been used in military field medicine with great results. I do not think that having a MD or a MICA medic make the effectiveness of the drug, but the training and experience. Yes, it does have some downsides, like all medications. However I do not feel that we need to start double blind studies to prove that it does work, just have to ensure the training is given along with it.

I don't doubt that it can do what it says it does, but is it better and/or safer than what is already used?  And one does not necessarily need to perform an RCT (though ideal) to get an idea of safety and efficacy.     

Scott Lancaster said:

Perhaps. It has also been used in military field medicine with great results. I do not think that having a MD or a MICA medic make the effectiveness of the drug, but the training and experience. Yes, it does have some downsides, like all medications. However I do not feel that we need to start double blind studies to prove that it does work, just have to ensure the training is given along with it.

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