Reuben Strayer, MD

Emergency Medicine Physician who works in New York City

Author of emupdates.com

One of the authors of painandspa.org

Twitter @emupdates

Created the phrase “ketamine brain continuum”

No financial disclosure

Back in 2015, Reuben gave an amazing talk on the subject of ketamine and its uses in Emergency Medicine at the SMACC Chicago conference.  It has a lot of fun slides too!

I recommend listening to Reuben’s SMACC talk first, and then listen to this podcast episode and refer to the show notes.

This talk got pretty in depth and long so I broke it up into 3 separate episodes.

Today’s episode is Part 1, an Introduction to Ketamine.  Part 2 and 3 will cover the applications of Ketamine in the ED in detail.

Ketamine

Ketamine is traditionally used as an anesthetic in the operating rooms. However, in many ED units, it’s commonly used as a procedural sedation agent and an induction agent for intubation. We will be talking about off-label uses including low dose ketamine for analgesia. Take note, you should know your institution’s policies. If you don’t have one, maybe you can develop some!

Safety Alert

• Must know how to monitor patients who receive ketamine for periods of apnea, psychomimetic disturbances, hypertension, tachycardia.
• Must have an airway capable provider at the bedside who can quickly intubate if necessary
• Weight based dosing on all patients.
• Keep 1 concentration of Ketamine in your ED
  • 2 different concentrations: 100mg/mL and 50mg/mL
  • I like the 50mg/mL concentration and prefer the single-use vials
    • It’s easier to push ketamine slower with the weaker concentration.  Otherwise, you can dilute the ketamine.
    • Drawing up ketamine is easier when you want smaller analgesic doses.

Also used as a recreational drug (street drug)

a.k.a. Special K (not the breakfast cereal), Kit Kat, K, Vitamin C, Cat Valium

Major Unwanted Side Effect – Psychomimetic Disturbances or Psychiatric Distress or “K-Hole” (slang) or in other words, they “freak out!”

• “K-hole” Wikipedia definition: a slang term for the subjective state of dissociation from the body commonly experienced after sufficiently high doses of the dissociative anesthetic ketamine.
• “K-hole” Urban Dictionary definition (my personal preference): To have used too much of the drug ketamine (special K) and lost sense of time and space, balance, verbal skills.
• My definition: They are high or stoned out of their mind.
• Patients can have a good high or a bad high. You’ll know the difference right away.
• You have the power to create a good or bad high.

How to mitigate unwanted psychomimetic disturbances?

• Therapeutic Communication
• Administer the medication extremely slowly.
• More evidence is showing that the best way is to dilute your dose into a NS 50mL saline bag (please label it!) and hang it so it’s infused in 15 minutes.
• If you do a traditional bolus push, 3-5 minutes is needed to mitigate psychomimetic disturbances.
• Give more ketamine to get your patient dissociated.
• Give propofol to counter ketamine’s effects.
• Give midazalam as another option.

Overdosing on ketamine

• Just prolongs the duration of dissociated state in patient.
• Look at the Ketamine Brain Continuum slide, the ketamine dosing curve plateaus after the dissociated dose has been reached.
  • Remember, ketamine is weight-based dosing, dosages shown in the slide are for your average adult size.

Now listen to the show…

1. Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/
2. Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 66(3). doi:10.1016/j.annemergmed.2015.03.004 https://www.ncbi.nlm.nih.gov/pubmed/25817884
3. Lee, E. N., & Lee, J. H. (2016, October 27). The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis.  https://www.ncbi.nlm.nih.gov/pubmed/27788221
4. Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017; S0735 – 6757(17): 30171 – 7.  PMID: 28283340
5. Ketamine: How to Use it Fearlessly For All its Indications by Reuben Strayer. (2015, December 06). https://www.smacc.net.au/2015/12/ketamine-how-to-use-it-fearlessly-for-all-its-indications-by-reuben-strayer/
6. Strayer, R. (n.d.). The Ketamine Brain Continuum. http://emupdates.com/?s=ketamine
7. The POKER Trial: Go All in on Ketofol? (2016, November 25). Retrieved August 25, 2017, from http://rebelem.com/poker-trial-go-ketofol/ http://rebelem.com/poker-trial-go-ketofol/
8. PharmERToxGuy, A. (2017, March 19). How to Administer Low-Dose IV Ketamine for Pain in the ED. https://pharmertoxguy.com/2017/03/06/how-to-administer-low-dose-iv-ketamine-for-pain-in-the-ed/
9. Allen, C. A., & Ivester, J. R. (January 01, 2017). Ketamine for Pain Management-Side Effects & Potential Adverse Events. Pain Management Nursing. http://www.painmanagementnursing.org/article/S1524-9042(17)30383-1/fulltext

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