A Special K Trip Part 3 (Analgesia & Tranquilization) w/Reuben Strayer, MD

009 A Special K Pain Diet

Who is Reuben Strayer, MD?

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Courtesy of 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

A Special K Trip Part 3 – Ketamine for Analgesia & Tranquilization

And now for the conclusion of the 3-part ketamine series with Reuben Strayer. Today’s episode is Part 3 focusing on Ketamine for analgesia and extremely uncontrollable violent patients.

If you haven’t already, go back and listen to Episode 7 where Reuben talks about ketamine and how different dosing can have different applications in the ED setting. In Episode 8, Reuben talks about ketamine for PSA & RSI.

Ready to continue with your Ketamine trip w/Reuben? Here we go!

Ketamine for Analgesia

Who gets ketamine? Chronic pain, poly trauma, oncology pain, etc.

Dosing

  • 0.3mg/kg
  • 0.1-0.3mg/kg have been used.

No pumps for bolus dose? No problem.

  • Of course, administering through a pump will always be the gold standard.

How to administer:

  • Inject the analgesic dose into NS 100mL and infuse over 15 minutes.
    • 15 minutes = 400mL/hr (best!)
    • 10 minutes = 600mL/hr (not much difference)
  • Why are we diluting the ketamine dose for administration? To prevent psychiatric emergence or your patient from “freaking out.”
  • Ketamine drips – always use a pump. (Not everyone will get a drip)
    • 0.1mg/kg and titrated every 30 minutes.
  • No monitoring required.
    • *Use your discretion, if you feel that your pt needs monitoring – put your patient on a monitor and alert your provider.

Some pretty good articles, full list below:

Ketamine for Tranquilization

Who gets it? Your huge guy where you have a small army of security and staff trying to hold him down and you are concerned for the patient’s and staff’s safety.

How often are you using this? Rarely.

Dose

  • Dissociative Intramuscular (IM) Dose: 4-6mg/kg
  • 500mg IM Adult dosing = approx. 100kg person

Monitoring required with airway capable provider at bedside. 

Safety Pearl for Violent and Agitated patients (whether you use ketamine or not):

  • Don’t attempt to put in an IV line! (If your provider asks, say “No thank you!”)
  • Administer IM through the clothing.
  • No alcohol swab needed.
  • Team approach to hold down patient for patient and staff safety.

Now Listen to the Episode…

References
  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
  10. Sergey Motov, MD and Nicholas Genes, MD, PhD. (2017, April 27). Motov’s Cocktails: Sub-Dissociative Ketamine. http://epmonthly.com/article/motovs-cocktails-sub-dissociative-ketamine/