Ketamine for Acute Pain Relief in the Emergency Department

Image credit: Flickr

Author: Kasha Bornstein, MSc EMT-P MSIII
University of Miami Miller School of Medicine MD/MPH Program, AAEM/RSA Modern Resident Blog Copy Editor

Bottom Line Up Front:
In comparison to 0.1mg/kg intravenous morphine, multiple studies demonstrated 0.3-0.5mg/kg ketamine was as effective in short term management of acute pain, without any increased risk of severe adverse effects. In addition to primary analgesia, ketamine may be effective as an analgesic adjunct in situations where opioids are contraindicated or for patients who have pain refractory to conventional pharmacologic approaches.

Introduction:
In the setting of the contemporary opioid epidemic, use of opioids for pain relief in the emergency department (ED) has been scrutinized. Opioid prescription presents increased risk for development of opioid use disorder and presents challenges for attainment of adequate pain control in opioid tolerant patients. Alternatives to opioids are an important topic of discussion in emergency medicine as well as in pain management subspecialties. Many institutions are adopting ketamine for analgesic use based on observational data and/or provider choice, but until recently, the high-quality evidence validating ketamine using randomized controlled trials (RCTs) has been limited. This article details a meta-analysis of RCTs comparing low-dose ketamine (LDK) to morphine for analgesia.

Drug Choice for Procedural Sedation: Propofol vs. Ketamine

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Author: Randy Kring, MSIV
Tufts University School of Medicine

Procedural sedation is frequently performed in the emergency department, whether it is for electrical cardioversion, closed joint reduction or abscess incision and drainage. Although the focus in these cases is often on the procedure, smart preparation for procedural sedation and an understanding of the different strategies that can be used is vitally important.

The goal of procedural sedation is to provide moderate sedation and analgesia while preserving the patient’s protective airway reflexes, adequate ventilation and cardiovascular function. Relative contraindications for procedural sedation may include advanced age, significant medical comorbidities such as CHF or COPD or signs of a difficult airway.[1] Recent food intake is not a contraindication for procedural sedation, but aspiration risk should be assessed and minimized whenever possible.[2] Many drugs can be used for procedural sedation, including midazolam, etomidate, propofol and ketamine. Which drug is “the best?”

Propofol, a sedative and amnestic, has onset in about 40 seconds and duration of action of about six minutes. Common side effects include pain at the injection site, hypotension and respiratory depression.[3] Ketamine, a dissociative anesthetic that provides sedation, amnesia and analgesia, has onset in about 30 seconds and duration of action of about 10 to 20 minutes. Common side effects include agitation on emergence, nausea and (rarely) tachycardia and hypertension.[4]

Did You Know?... Ketamine in Head Trauma

Originally Published: Modern Resident, Dec/Jan 2012

Original Author: Casey Grover, MD Stanford/Kaiser Emergency Medicine

Submitted by: Rachel Engle, DO Communications Committee Chair

We all learned in medical school that increased intracranial pressure is a contraindication to the use of ketamine...