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

Ready to continue your Special K Trip?

Today’s episode is Part 2 out of a 3-part series and will cover the use of ketamine for procedural sedation and intubations in the ED with Reuben Strayer, MD.

If you didn’t listen to Reuben talk about ketamine, the safety measures of ketamine, or confused by this graphic with different dosing – go back and listen to Episode 7 for Part 1 where this is explained in detail.

Ketamine for Procedural Sedation and Analgesia (PSA)

Prep Your Patient

• Therapeutic Communication – let your patient have whatever fantasy they want and encourage it! Any fantasy can be a reality with ketamine…seriously.
• If they are in so much pain that they are already freaking out and you’re not doing your procedure you can give opioids to help calm them down – but remember, ketamine is a powerful analgesia as well…you can always keep them dissociative for a longer duration of time. Situation dependent.
• Administer your ketamine dosage diluted in Normal Saline and give it slow…best method to prevent psychiatric disturbance.

Prep Yourself

• Place patient on continuous telemonitoring and pulse oximetry
  • Bonus points: CO2 monitoring
• Airway capable Doctor
  • Watch respirations and breathing closely
  • May have periods of apnea
    • Prevent apnea by administering ketamine slowly (approx. 2 minutes diluted or diluted in Normal Saline 50/100mL over a longer period of time)
    • Expect apnea if you administer ketamine as a fast IV push bolus (1-2 seconds)
    • Patient may still have apnea – MD must know maneuvers to open airway (head position, jaw thrust, BVM, intubation)
• Nasal Cannula on patient – turn on oxygen as needed
  • I like to have everything connected even if the oxygen is turned off
  • NRM on standby
• Airway Cart, BVM, and Intubation Kit on standby
• Suction on standby
• Nurse who is dedicated to monitor sedation – lots of paperwork and frequent monitoring including watching those respirations!
• Consent

PSA Ketamine Dose

• Reuben gives a dissociative dose (Ketamine 1-1.5mg/kg). You can get away with giving an analgesic dose but if a patient comes in with a bad fracture – give the dissociative dose and have propofol on hand to counter ketamine’s side effects.
• Ketamine can be used as monotherapy for PSA.
• Propofol – to counter ketamine’s effects (HTN, muscle rigidity, psychiatric emergence, etc.)
  • Draw up in separate syringe.
  • Administer in 20/30/40mg IV pushes as needed
• Ketofol – Effective but you are not dosing propofol separately.
  • What is it? Ketamine and propofol drawn up in single syringe and administered at the same time.

Always Treat Psychiatric Disturbance

As your patient metabolizes the ketamine, your patient may “freak out” or have a psychiatric emergence and you must always treat it. It’s inhumane to not ignore it and let the patient “ride it out.”

Use conventional medications to treat: propofol, midazolam, haloperidol, droperidol (if you can get your hands on it)

Post PSA Ketamine Pearls

• NPO until fully alert.
• Don’t stimulate patient prematurely.
• Minimal noise and minimal physical contact.
• Nurse with patient entire time monitoring patient until fully alert.

Ketamine for Rapid Sequence Intubation (RSI)

• Okay to use for polytrauma or head trauma (ICP) patients.
• Has neuroprotective properties – good for ICP/head trauma patients.
• Induction agent independent from paralytic – doesn’t matter if you use rocuronium or succinylcholine – but we are fans of rocuronium for RSIs in the ED.
  • Roc Rocks vs. Sux Sucks -LITFL
• Extra Ketamine in your syringe?
  • Can use like a push dose pressor while setting up post intubation drips.

Dissociative Dosing

Ketamine Dissociative Dose 1-1.5mg/kg, but as low as 0.75mg/kg.

Once your patient is dissociated, if you give more ketamine – it just increases the duration. Your patient will not get “more dissociated.”

Population Contraindication

• Aortic Dissection
• Cocaine/PCP Intoxicated
• Thyroid Storm
• Hypertensive Emergency Patient
• SAH
• Heart Failure (not a complete contraindication)

Population Caution

• Heart Disease with Hypertensive Problems (BP can be treated with Propofol/) – Clinical Decision case to case
  • Ex: Elderly patient w/Heart Disease, cannot tolerate increased BP or tachycardia and concern for ketamine increasing after load = Acute Heart Failure

Now Listen to the Episode…

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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