# Ketamine



## amlove21 (Jan 17, 2012)

Since it was mentioned in another thread, I decided to start one here. Ketamine is an awesome, awesome drug. I have a good deal of personal experience with it, and find it to be the second best trauma pain management drug out there, the first being a heavy (12 or 1600mcg) Fentanyl lollipop. I am a huge proponent for Ketamine but have run into some opposition, mostly due to ignorance. So, let's take care of that. 

Discuss any experience, rumors, urban legends, secondhand legends, or facts here. The more discourse the better for everyone. I included a quick fact sheet for a base of knowledge. This specific source is from an anesthesiology stand point, but it'll do, pig. It'll do.


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## TLDR20 (Jan 17, 2012)

Ketamine is a terrific drug, increases HR, respirations and BP, while making the patient not care about his pain.


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## Muppet (Jan 17, 2012)

It was used for a bilat. field amputation a few years back in my local by my medical director, used I.M. because I.V.'s were not available @ the time / poor access and it was before EZ-IO's were cleared to use, 6 years ago. I was told it work well w/o adverse hemodynamics. It is in the U.SA.R. S.O.P.'s for my area for pain mangement along with the typical pain meds. / not in P.A. DOH protocols yet though.

F.M.


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## policemedic (Jan 17, 2012)

Tagged for later


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## LibraryLady (Jan 17, 2012)

All I remember about Ketamine is that it's the biggest reason vet clinics are broken into - apparently it's a supreme high for junkies.

LL


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## Muppet (Jan 17, 2012)

LibraryLady said:


> All I remember about Ketamine is that it's the biggest reason vet clinics are broken into - apparently it's a supreme high for junkies.
> 
> LL


 
Yea. Is has dissociative properties that act like L.S.D.

F.M.


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## Wench (Jan 17, 2012)

My experience is all street-use related.  No way in hell I'd ever sign up for it based off of that, YMMV.  The cons of its side effects outweigh the pros of its efficacy, IMHO.


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## Mac_NZ (Jan 17, 2012)

I know our medics raved about it, especially the lollipops.


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## amlove21 (Jan 17, 2012)

Wench said:


> My experience is all street-use related. No way in hell I'd ever sign up for it based off of that, YMMV. The cons of its side effects outweigh the pros of its efficacy, IMHO.


I'm interested to hear which cons those are. I dont mean that in an accusatory tone- I really am interested. Can you elaborate?



cback0220 said:


> Ketamine is a terrific drug, increases HR, respirations and BP, while making the patient not care about his pain.


Furthermore, it disassociates the patient from the event (and more importantly the concurrent treatment) making the event less psychologically damaging. There is a study out there on return to work times when ketamine is compared to morphine. Pretty interesting- I'll find it. 



Firemedic said:


> It was used ... I.M. because I.V.'s were not available @ the time / poor access and it was before EZ-IO's were cleared to use... it works well w/o adverse hemodynamics. F.M.


I will co-sign this 100%. I have talked to a couple people that have stated some longer action times (one as many as 10 minutes from injection IM to onset), but I have personally seen great effect on a hemodynamically unstable PT in less than 3 minutes. For a healthy guy IM? It's nearly immediate- less than a minute in some cases (first had there also). That's one of the reasons I like the fentanyl lollipops too- immediate relief, ease of administering the drug, and extremely low repercussions- side effect wise. Ketamine rarely knocks someone's respiratory drive out completely, and if it depresses it? Just wait a second, the half life is very short. As for fentanyl, you don't need a line for narcan.


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## TLDR20 (Jan 17, 2012)

Wench said:


> My experience is all street-use related.  No way in hell I'd ever sign up for it based off of that, YMMV.  The cons of its side effects outweigh the pros of its efficacy, IMHO.



The street use side effects of abuse? I can show you a bunch of people addicted to opiates, that doesn't take away the medical efficacy of morphine! Ketamine puts other drugs to shame for anesthesia properties.

I am also legitimately curious about what side effects outweigh its efficacy.


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## policemedic (Jan 17, 2012)

cback0220 said:


> The street use side effects of abuse? I can show you a bunch of people addicted to opiates, that doesn't take away the medical efficacy of morphine! Ketamine puts other drugs to shame for anesthesia properties.


 
Precisely why I'm excited the CoTCCC is seriously considering its inclusion into the PHTLS protocols.  It's not that ketamine isn't available, but I think including it in PHTLS will expand both its use and perhaps the number of clinicians who can administer it.


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## surgicalcric (Jan 17, 2012)

Wench said:


> ...The cons of its side effects outweigh the pros of its efficacy, IMHO.


 
I would love to hear what you believe the cons to using Ketamine in a clinical/field setting are.


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## Brill (Jan 17, 2012)

cback0220 said:


> Ketamine is a terrific drug, increases HR, respirations and BP, while making the patient not care about *his* pain.


 
Please tell me you're using that downrange only and NOT on Thursdays.


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## Muppet (Jan 17, 2012)

It would be really nice if ketamine were able to be used with a M.A.D. (mucosal atomisation device) like versed and ativan. That would be really cool.

F.M.


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## policemedic (Jan 18, 2012)

Firemedic said:


> It would be really nice if ketamine were able to be used with a M.A.D. (mucosal atomisation device) like versed and ativan. That would be really cool.
> 
> F.M.


 
Ketamine can be administered IN.


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## policemedic (Jan 18, 2012)

Wench said:


> My experience is all street-use related. No way in hell I'd ever sign up for it based off of that, YMMV. The cons of its side effects outweigh the pros of its efficacy, IMHO.


 
I'm guessing you're referring to the emergence phenomena.    The short answer is that this can be managed very well with IV benzodiazepines, particularly midazolam.  In fact, that's one of the charms of ketamine-it lends itself quite well to multimodal analgesia.  There is a world of difference between Special K dosing and administration routes/techniques in use by recreational users and proper use by trained professionals (who are also at the bedside when the analgesia begins to wear off).

Every drug has side effects, but if a bullet has just flown through my femur, I want ketamine.


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## amlove21 (Jan 18, 2012)

policemedic said:


> I'm guessing you're referring to the emergence phenomena. The short answer is that this can be managed very well with IV benzodiazepines, particularly midazolam....Every drug has side effects, but if a bullet has just flown through my femur, I want ketamine.


 
Right  on here. Standard protocol for us is 2-4 Versed along with ketamine. This practice reduces the effect coming out of the ketamine, and allows for great pain control. If you have someone that's really hurting and awake? Fentanyl lollipop transbucally (800mcg), 1-1.5mg/kg ketamine IM, 2-4 mg midazolam.


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## Wench (Jan 18, 2012)

Tsk tsk tsk such anger LOL. I didn't claim to be a medical professional (just an EMT wwwaaayyyy back in the day), I just stated that in my experience it seems to create side effects that I haven't seen in others that are also commonly used in street drugs. If other things can give the same relief without giving the effects that I have seen, why use it? (genuine question there) Why isn't it more commonly used, if it's so great? Why isn't in the protocols for more EMS/ER systems? I'm not saying it's altogether bad, I'm just saying *I* don't want it (not that I would necessarily have a choice, if cback220 is looming over my unconscious self ) .

"Despite ketamine’s use for four decades to produce general anesthesia at high doses, evidence to guide its use at subanesthetic doses for pain control is limited and in part contradictory. Depending upon the setting and the study design, some papers describe significant benefit and almost as many report limited or no efficacy. At least three meta-analyses for acute pain relief report good data to support its use; however, solid data are sparse concerning its use for chronic noncancer and cancer pain. Currently available evidence suggests that ketamine’s utility is less as an analgesic per se, and more as an antihyperalgesic, antiallodynic, or tolerance-protective agent for pathological pain states such as severe acute pain, opioid tolerance or hyperalgesia, neuropathic pain, cancer pain, or visceral pain. Ketamine may also have preventive analgesia effects and in some cases may reduce the incidence of chronic postsurgical or post-traumatic (e.g., phantom limb) pain. These effects reflect its activity at the NMDA receptor, which is not involved in normal or physiological nociception but is activated by intense or prolonged nociceptive barrages that induce central sensitization and pathological pain. Adequate knowledge to prescribe this drug in a rational, evidence-based manner will require large, high-quality studies that assess both immediate and longer-term outcomes. We must either investigate and delineate the role of this intriguing drug in pain medicine or let it slip quietly into retirement.

"Administration of S(+) ketamine for acute pain relief after trauma increased post-traumatic stress disorder symptoms at one year compared to racemic ketamine or an opioid."

The above quotes are from the International Association for the Study of Pain, 2007.

Sorry, it won't let me reformat the font above to a more readable type.


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## amlove21 (Jan 18, 2012)

Wench said:


> Tsk tsk tsk such anger LOL.... If other things can give the same relief without giving the effects that I have seen, why use it? (genuine question there) Why isn't it more commonly used, if it's so great? Why isn't in the protocols for more EMS/ER systems? I'm not saying it's altogether bad, I'm just saying *I* don't want it (not that I would necessarily have a choice, if cback220 is looming over my unconscious self ) .
> 
> 
> "Administration of S(+) ketamine for acute pain relief after trauma increased post-traumatic stress disorder symptoms at one year compared to racemic ketamine or an opioid."
> ...


 
This is good! So I am going to take your points by point. By the way, no anger here- but lots of medical discussions start with a friendly "prove it", and that doesnt translate well on teh interwebs.  

- Other things (like opiods) CANT give the same relief. While morphine and fentanyl can dull your pain a bit, we all have a story about how "we saw this one dude take 30mg morphine IV and still scream". All trauma drugs are not created equal, and ketamine works in a different way (on the NDMA receptor, for the super geeks). We should use it because it's better for trauma- it's side effects are increased respiration (to a threshold point), increased blood pressure (due to peripheral vasoconstriction), and dilation of the bronchioles (bigger tubes for air to get in).

-Well, first off I would say it's not better understood because it was used primarily for animals and children until the Brits put it into wide use in trauma in the 70/80's time frame. The two focus groups (dogs and kids) have a hard time articulating the efficacy of a drug, you know what I mean? It's not commonly used because pain management as a whole isnt commonly used in the EMS systems we have today. It's the same reason tourniquets arent commonly used to stop bleeders. In TCCC, the tourniquet is the first step for any red stuff- if you did that in the EMS world, holy shit look out. Paramedics with short transport times rarely need to pass pain meds, because they will be at the hospital soon, and they can avoid potential liability. Hell, most rides you dont even stick an IV. I am not encompassing all EMS systems, but I feel pretty confident in saying that without a major backlash. Short answer? We dont see it more because the EMS world has taken a long time to catch up to the combat medicine world for more than 10 years now. Well, that's one reason, but it's also another thread. I digress. 

-I think if you were hurt, and I was treating you, I would give you ketamine and versed. Not because I own stock in those companies, but because I have seen it control pain better than almost every opiod out there, and if I need to do something hurtful to you to make you better, I want you taken care of. That's just me. But I would bet you thank me later. 

And to address the PTSD study- look here and here. You'll find studies that directly refute the institute of pains study. As a matter of point, ketamine is one of the leading edge _treatments _for PTSD now (here is a link to that study). And one note on that study- finding that ketamine DID but racemic ketamine DIDNT lead to PTSD is spurious at best. Same compound (albeit a balanced L/R isomer balanced in the racemic), same effects, but a lower incidence of PTSD? I would call polite BS, but I will do my research.


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## policemedic (Jan 18, 2012)

amlove21 said:


> This is good! So I am going to take your points by point. By the way, no anger here- but lots of medical discussions start with a friendly "prove it", and that doesnt translate well on teh inter webs.


 
No anger here either, Wench; threads like these are fantastic tools for educating, learning, and examining a topic from a somewhat multidisciplinary viewpoint. I'm going to throw in a few points off the cuff here, interspersed with amlove21 's comments. Many medical techniques and devices were adopted without proper study e.g. MAST trousers, so evidence based discussions are always welcome. I believe if you put forth a treatment modality, you bear responsibility for defending why it is better than something else in similar circumstances. I'm looking forward to Red Flag 1 's input on this question.



amlove21 said:


> - Other things (like opiods) CANT give the same relief. While morphine and fentanyl can dull your pain a bit, we all have a story about how "we saw this one dude take 30mg morphine IV and still scream". All trauma drugs are not created equal, and ketamine works in a different way (on the NDMA receptor, for the super geeks). We should use it because it's better for trauma- it's side effects are increased respiration (to a threshold point), increased blood pressure (due to peripheral vasoconstriction), and dilation of the bronchioles (bigger tubes for air to get in).


 
Spot on. Opioids work on pain in one way; ketamine works differently. We want to be able choose the right medication based on the pt's presentation. Sometimes, IV/IM MSO4 is sufficient (Lord knows I've given it quite a bit). Sometimes, a fentanyl lollipop is sufficient. But there are times when neither opioid is sufficient unto itself, and may not even be appropriate for the procedure being conducted. In these cases, we need a more effective option. Ketamine fits the bill because of its rapid onset, short half-life, beneficial hemodynamic and respiratory effects. Better still, because it antagonizes glutamate, it is well-suited for multimodal analgesia and sedation.



amlove21 said:


> -Well, first off I would say it's not better understood because it was used primarily for animals and children until the Brits put it into wide use in trauma in the 70/80's time frame. The two focus groups (dogs and kids) have a hard time articulating the efficacy of a drug, you know what I mean? It's not commonly used because pain management as a whole isnt commonly used in the EMS systems we have today. It's the same reason tourniquets arent commonly used to stop bleeders. In TCCC, the tourniquet is the first step for any red stuff- if you did that in the EMS world, holy shit look out. Paramedics with short transport times rarely need to pass pain meds, because they will be at the hospital soon, and they can avoid potential liability. Hell, most rides you dont even stick an IV. I am not encompassing all EMS systems, but I feel pretty confident in saying that without a major backlash. Short answer? We dont see it more because the EMS world has taken a long time to catch up to the combat medicine world for more than 10 years now. Well, that's one reason, but it's also another thread. I digress.


 
The literature describing the safety and efficacy of ketamine in the pediatric population is quite robust. The UK and Israelis have used it extensively in tactical medicine, which is after all exactly the setting we are discussing. They are big fans. In fact, the Israelis promulgated a protocol for sedation of combative trauma pts with IV/IM ketamine.

It's true that pain management in EMS sucks. Some of this is due to apathy on the part of a burned-out big city medic, some of it is poor education, and a great deal of it is due to the disinterest of EMS medical directors. Add that there is still a belief prevalent in some areas that abdominal pain (I'm speaking generally here) pts should not receive prehospital pain management, some neuro docs don't like it (some of this is the result of poor medication selection/protocols, IMO), and you begin to see why pain management isn't standard of care nationwide. Also, one must consider who exactly is allowed to manipulate narcotics/benzos/etc. Generally, this requires a paramedic (though there may be states that delegate this to intermediates). You are not always going to be treated by someone of sufficient training to manage your pain with parenteral medications. Proper pain management by paramedics is a _big deal_ to me.

More later.


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## policemedic (Jan 18, 2012)

amlove21 said:


> Short answer? We dont see it more because the EMS world has taken a long time to catch up to the combat medicine world for more than 10 years now. Well, that's one reason, but it's also another thread. I digress.


 
In some ways, I agree. In others, though...not so much. But you're right; that's a whole new thread.




amlove21 said:


> -I think if you were hurt, and I was treating you, I would give you ketamine and versed. Not because I own stock in those companies, but because I have seen it control pain better than almost every opiod out there, and if I need to do something hurtful to you to make you better, I want you taken care of. That's just me. But I would bet you thank me later.


 




amlove21 said:


> And to address the PTSD study- look here and here. You'll find studies that directly refute the institute of pains study. As a matter of point, ketamine is one of the leading edge _treatments _for PTSD now (here is a link to that study). And one note on that study- finding that ketamine DID but racemic ketamine DIDNT lead to PTSD is spurious at best. Same compound (albeit a balanced L/R isomer balanced in the racemic), same effects, but a lower incidence of PTSD? I would call polite BS, but I will do my research.


 
I read the newsletter Wench referenced above. It provided some interesting viewpoints, but it bears mentioning that the writers approached the subject from the standpoint of anesthesiology with a slant towards chronic pain management. Regardless, they mention several times in that newsletter that ketamine is clearly effective, and often is able to control pain opiate infusions could not (or resulted in decreased dosing of opiates in conjunction with ketamine). They also address the use of ketamine for conditions most military medics will never see e.g. longterm management of cancer pain. It did not support the opinion that ketamine is unsafe, inefficient, or inappropriate for the control of acute pain secondary to traumatic injury.

With regard to the study the newsletter authors quoted which expressed the opinion that ketamine resulted in an increased occurrence of PTSD at one year post-incident, I'll simply say that after reviewing the full paper (attached to this post) I found it to be poorly constructed, underpowered, and somewhat deceptive in its implementation. I tend to be unimpressed when people attempt to draw complex conclusions from a study with an _n_=56 and numerous uncontrolled variables.

For what it's worth, ACEP supports the use of ketamine by its members. Their clinical guideline is attached as well.


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## Red Flag 1 (Jan 21, 2012)

_I'm looking forward to Red Flag 1 's input on this question._ Thanks, sorry for the delay. During my residency, Ketamine was a new agent, seeing use as an induction agent for general anesthesia. It is a dissociative agent (DA), like LSD. Dissociative episodes then were treated with our only benzo..Valium. It was thought to be, in part, related to the recovery room time. We would recover DA pts in a seperate area of the PACU with no lights, no sound, and few vital sign. Left alone in the dark for recovery just scared the crap out of me.

I recall one young lady having a D&C with mostly Ketamine. The case I staffed seemed to go just fine with great compliance from the "awake" patient. I spoke with her the next day and she said she was scared witless of a full grown tiger across the room that was going to pounce on her if she moved or made a sound. I was stunned at her reply and modified my opinion of Ketamine used in that manner. There were USAF patients having flashback episodes after anesthetic doses of Ketamine. Ketamine was banned from use on any patient on flying status, armed, or solo medical providers such as myself. That pretty much kept the drug out of USAF usage at all. I have used it as an agent for things since.

It is a very good analgesic used in smaller doses. I have used Ketamine to help patients with any pain associated with regional blocks. It has not replaced Fentanyl, nor all it's children, as an analgesic in my mind at least. The purist in me still thinks of narcotics for pain relief with benzos, and Ketamine as an adjuct to "try" for just a little kick. Ketamine does support the BP better that other induction agents, and would be useful in shocky patients, I have used it for those cases with no complications later.

Ketamine does have it's place in pain relief. It does support vital signs better that narcotics, and is therefore useful. I would continue to go to narcotics first and save Ketamine as an adjunct. Be mindful that it iks and LSD like agent with complications at higher doses. The complications are worth consideration.

Good thread, great discussion.....as always.

RF 1


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## Jerry Barrett (Mar 22, 2012)

Sorry guys, I'm back on forum down in Oz.
Ketamine, yea best trauma analgesic there is! Beats the pants off of Morphine as it works for you in the field maintain airway structure , increase cardiac output, increase rate.....Not good for medical cardiac pain for the reasons I just gave [supply & demand] and not good for head injury/ eye injury due to the increased ICP/ IOP. The emergence syndrome that people whine about is only common if you give in anaesthesia dose [WFT are you doing that for?], and should you be a bit heavy handed with the dose per kg then your patient ends up aneasthetised and not crashed!
We trialed it in teh British Army back in the early 90's for battle field surgey, continuous flow IV anaesthesia mixed with Midazolam and it worked a treat, better and more practical than propofol
Big thumbs up!


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## Squidward (Nov 13, 2012)

Had an RFI the other day on the how useful Ketamine auto-injectors (50MG dose) would be for SOF medics. Any thoughts or considerations?


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## Red Flag 1 (Nov 15, 2012)

Squidward said:


> Had an RFI the other day on the how useful Ketamine auto-injectors (50MG dose) would be for SOF medics. Any thoughts or considerations?


 
There is a lot to support the use of Ketamine for treating acute pain. Amlove21 is a big proponent of Ketamine, and I agree with him; reply #19 really says a lot . Along with Ketamine's ability to provide analgesia, it can also induce surgical anesthesia in higher dosages. For induction of anesthesia, I have used 100mg/ml Ketamine as an intramuscular injection to induce anesthesia. There is a "war story", or five, using this method; pm me for details, film @ 2300hrs . One of the things that supports it's use, is Ketamine's sympathomimetic abilities. Ketamine will provide better hemodynamic support if you are looking at any degree of blood loss; opioids will not be able to do that for you. Patients that came to me in the ER or OR, with any hemodynamic instability due to hemorrhage, generally were administered Ketamine as an induction agent. Narcotics would be added slowly later as the clinical picture improved.

Ketamine is an agent that not only provides analgesia, but also is a dissociative; that sort of takes the brain away from the pain, as well. That is the part of Ketamine that suggests care be taken with administration. My rule of thumb, was to add Versed when clinically able to do so.

RF 1


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## Squidward (Nov 16, 2012)

Red Flag 1 said:


> There is a lot to support the use of Ketamine for treating acute pain. Amlove21 is a big proponent of Ketamine, and I agree with him; reply #19 really says a lot . Along with Ketamine's ability to provide analgesia, it can also induce surgical anesthesia in higher dosages. For induction of anesthesia, I have used 100mg/ml Ketamine as an intramuscular injection to induce anesthesia. There is a "war story", or five, using this method; pm me for details, film @ 2300hrs . One of the things that supports it's use, is Ketamine's sympathomimetic abilities. Ketamine will provide better hemodynamic support if you are looking at any degree of blood loss; opioids will not be able to do that for you. Patients that came to me in the ER or OR, with any hemodynamic instability due to hemorrhage, generally were administered Ketamine as an induction agent. Narcotics would be added slowly later as the clinical picture improved.
> 
> Ketamine is an agent that not only provides analgesia, but also is a dissociative; that sort of takes the brain away from the pain, as well. That is the part of Ketamine that suggests care be taken with administration. My rule of thumb, was to add Versed when clinically able to do so.
> 
> RF 1



Myself and my senior have become big supporters of the drug as well because of the reasons listed above and in Amlove21's reply #19. Both myself and my senior added it to our kits early into our rotation after a case that would have benefited from its administration (GSW left knee: popliteal artery transection with marked hypovolemia [carotid pulse only until fluid resuscitation with hextend] pt remained conscious through the duration of treatment until medevac). Currently we both carry Ketamine in vials for either IM or IV administration according to current guidelines. However, the proposed dosage for the auto-injectors was 50mg across the board. Would this be adequate for its intended purpose/ is there a better dosing for Ketamine IM/IV/etc for battlefield analgesia?


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## policemedic (Nov 16, 2012)

Would you be replacing the vials or carrying both?  Auto injectors are faster, but vials give you more options and control.


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## Dame (Nov 16, 2012)

Red Flag 1 said:


> I recall one young lady having a D&C with mostly Ketamine. The case I staffed seemed to go just fine with great compliance from the "awake" patient. I spoke with her the next day and she said she was scared witless of a full grown tiger across the room that was going to pounce on her if she moved or made a sound. I was stunned at her reply and modified my opinion of Ketamine used in that manner. There were USAF patients having flashback episodes after anesthetic doses of Ketamine. Ketamine was banned from use on any patient on flying status, armed, or solo medical providers such as myself. That pretty much kept the drug out of USAF usage at all. I have used it as an agent for things since.
> RF 1


I didn't have quite the same reaction to it but close. From the patient POV, that stuff will mess with you. Maybe it's just my screwed up neurology but taking the pain away wasn't what I'd call it. More like it transforms pain into emotion. Fear, frustration, or whatever else. Doesn't surprise me about the PTSD rise in patients treated with it.


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## Red Flag 1 (Nov 16, 2012)

Squidward said:


> Myself and my senior have become big supporters of the drug as well because of the reasons listed above and in Amlove21's reply #19. Both myself and my senior added it to our kits early into our rotation after a case that would have benefited from its administration (GSW left knee: popliteal artery transection with marked hypovolemia [carotid pulse only until fluid resuscitation with hextend] pt remained conscious through the duration of treatment until medevac). Currently we both carry Ketamine in vials for either IM or IV administration according to current guidelines. However, the proposed dosage for the auto-injectors was 50mg across the board. Would this be adequate for its intended purpose/ is there a better dosing for Ketamine IM/IV/etc for battlefield analgesia?


 
My thinking is to give the amount of Ketamine needed by the administration route indicated. I prefer IV because of the control that route allows me, there is another reason for IV; particularly in the field. With large, and sometimes rapid, blood loss,  the IM route may not make into circulation. The body can shut down blood flow to parts of the body as it attempts to perfuse only critical organs. The IM administered amount will be left to pool in the muscles, only to be picked up later; when you have forgotten all about it. As long as you keep that limitation in mind, the auto injector with 50mg should work just fine.



Dame said:


> I didn't have quite the same reaction to it but close. From the patient POV, that stuff will mess with you. Maybe it's just my screwed up neurology but taking the pain away wasn't what I'd call it. More like it transforms pain into emotion. Fear, frustration, or whatever else. Doesn't surprise me about the PTSD rise in patients treated with it.


 
I don't know the clinical setting in which you were given Ketamine, Dame; and pm venue is best for individual discussion. I am sorry to learn of your experience, and if there is a reason to take care with Ketamine, this is it. As a dissociative drug, it takes the brain somewhere while the pain is being managed. Using Versed to occupy Gaba receptors, is a seen very good tool when Ketamine is used; and can blunt the psychological event. I have to say, that there have been times when I have had to delay giving anything that would add to any CNS depression, including Versed. That meant I would have to give it later than I would have liked to. That said, there may be people out there who have had the same experience you did, Dame; after I have cared for them. In addition to using Versed, doses of short acting, potent opioids (Fentanyl) are also a good idea when clinically safe to do so.

RF 1


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## Squidward (Nov 16, 2012)

policemedic said:


> Would you be replacing the vials or carrying both? Auto injectors are faster, but vials give you more options and control.



To be completely honest I'd given much thought to it yet. Doesn't even look like the auto-injectors will be available until after we leave. As it stands now, I'd say I'd take both. It depends though. We have yet to do any mounted ops, so at times space/weight is at a premium. For short duration ops (4 hours or less) when we're trying to go in as light as possible and I don't carry a large rucksack, I would consider leaving one behind. The vials would be my first choice due to the proximity of medevac assets. On longer operations (4-72 hours) I would carry both. However, a great compromise would be to get the drug in carpuject configuration. Currently all we have are the vials that require a traditional needle and syringe to draw/administer.



Red Flag 1 said:


> My thinking is to give the amount of Ketamine needed by the administration route indicated. I prefer IV because of the control that route allows me, there is another reason for IV; particularly in the field. With large, and sometimes rapid, blood loss, the IM route may not make into circulation. The body can shut down blood flow to parts of the body as it attempts to perfuse only critical organs. The IM administered amount will be left to pool in the muscles, only to be picked up later; when you have forgotten all about it. As long as you keep that limitation in mind, the auto injector with 50mg should work just fine.RF 1


 
Great point. That being considered I'd say I'm leaning more towards carrying both forms of Ketamine if we ever get the auto-injectors. Could make space by removing the morphine auto-injectors I usually take with me. Putting thought into it not all patients we run into are Americans, and because of that not all of them are guaranteed a medevac. Sometimes it takes time to organize a local national ground transport. In that case I'd like a little more control and flexibility. However, if we ever get Ketamine in carpuject vials I would probably take that over both auto-injectors and traditional vials. Always looking to take things that have multiple uses.


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## Dame (Nov 16, 2012)

Red Flag 1 said:


> I don't know the clinical setting in which you were given Ketamine, Dame; and pm venue is best for individual discussion. I am sorry to learn of your experience, and if there is a reason to take care with Ketamine, this is it. As a dissociative drug, it takes the brain somewhere while the pain is being managed. Using Versed to occupy Gaba receptors, is a seen very good tool when Ketamine is used; and can blunt the psychological event. I have to say, that there have been times when I have had to delay giving anything that would add to any CNS depression, including Versed. That meant I would have to give it later than I would have liked to. That said, there may be people out there who have had the same experience you did, Dame; after I have cared for them. In addition to using Versed, doses of short acting, potent opioids (Fentanyl) are also a good idea when clinically safe to do so.
> 
> RF 1


 
Believe it or not, I have no clue what you just said.


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## Red Flag 1 (Nov 16, 2012)

Dame said:


> Believe it or not, I have no clue what you just said.


pm inbound.

RF 1


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## amlove21 (Nov 18, 2012)

Squidward said:


> ...entire post...


 
I'll throw my opinion out there- I don't have anything against the 50mg auto injectors, per se. I think the dosages is light for it's intended use (CoTCCC recommends 1-1.5 mg/Kg for analgesia), and I am not really gaining anything (time, ease of admin, ease of carry, etc) by having an auto injector vs. my normal method of carry/administration. I will echo Red Flag and say I prefer IV admin for the same reasons, but find IM to be just fine in a pinch. I guess the only real benefit of having auto injectors would be the "I don't need to be the guy giving the drug" aspect, and have my guys carry it. I prefer the vials for the flexibility of dosage, and my little "pelican case of happiness" (1G Ketamine, 200mcg fentanyl, 4 x 800mcg FentLos, and 10mg valium) is small enough for a cargo pocket or a 3 day. 

All that being said, I don't disagree with the auto injectors. If you try it/them, let us all know. I'd like to hear how they work.


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## Red Flag 1 (Nov 18, 2012)

amlove21 said:


> I'll throw my opinion out there- I don't have anything against the 50mg auto injectors, per se. I think the dosages is light for it's intended use (CoTCCC recommends 1-1.5 mg/Kg for analgesia), and I am not really gaining anything (time, ease of admin, ease of carry, etc) by having an auto injector vs. my normal method of carry/administration. I will echo Red Flag and say I prefer IV admin for the same reasons, but find IM to be just fine in a pinch. I guess the only real benefit of having auto injectors would be the "I don't need to be the guy giving the drug" aspect, and have my guys carry it. I prefer the vials for the flexibility of dosage, and my little "pelican case of happiness" (1G Ketamine, 200mcg fentanyl, 4 x 800mcg FentLos, and 10mg valium) is small enough for a cargo pocket or a 3 day.
> 
> All that being said, I don't disagree with the auto injectors. If you try it/them, let us all know. I'd like to hear how they work.


 
Is there the flexability, and room, for including Dilaudid ?

RF 1


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## amlove21 (Nov 18, 2012)

Red Flag 1 said:


> Is there the flexability, and room, for including Dilaudid ?
> 
> RF 1


No Doc, there isn't any flexibility on which drugs you can pack out in your personal gear.

The list of approved meds is restricted to the SOC Medical handbook, our own medical handbook and just recently included ketamine as a standard drug for the entire career field. There is always a "medical control" debate- in our regs, the Team leader accepts responsibility for medical treatment of all patients. This means that the docs that are technically our med control for real world missions has no real oversight of patient care prior to turning care over to whatever medical entity we are taking the pt to. The docs don't fly with us, and we rarely have time to get "no kidding" online med control.

For all these reasons new drugs hit the teams slowly, once everyone is convinced that new drug, whatever it is, is safe to administer, if it meets our needs, and so on. The "medical control" doc could feasibly never actually see the team.

Apparently giving us carte blanche to carry whatever we want is not the most appealing situation for physicians that only see the risk profile and frame that with their desire to not have their medical license revoked.


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## HoosierAnnie (Nov 18, 2012)

This has been a great revival of this thread for an RN no longer doing direct patient care (having moved into case mgmt)


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## Muppet (Nov 18, 2012)

HoosierAnnie said:


> This has been a great revival of this thread for an RN no longer doing direct patient care (having moved into case mgmt)


 
Having read this thread, I have used Ketamine in the USAR role and have used it I.M. and have had my medical director use it on a field amputation (bilat) with good results. I was not there for that though. I learned alot, thanks.

F.M.


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## Squidward (Nov 19, 2012)

Talking it over amongst a few guys here we all agreed 50mg was a bit light. As it stands now the auto-injectors are still in the "Would this be a good idea?" stage. After your last post amlove and a few conversations amongst colleagues I'd probably still stick with the vials only. Flexibility is always good, and in the end I'd always be lighter without the extra auto-injectors. As you said in your post an auto-injector is a great medium for distribution to team guys. In the end I think that's their intended purpose. In fact I'd rather distro Ketamine than opiates. We make it a point to cross-train ODA and enablers as much as possible. As you know, terrain can make 300m seem like an eternity, so it's important everyone can manage even if there's not a medic in the immediate vicinity. That being said everyone knows when opiates are contraindicated, but Ketamine in my mind would make things simpler. Looking forward to seeing what comes of it. I'll post the results up here if we do end up getting them this trip.


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## kaja (Jan 19, 2013)

So, would you prefer administering ketamine rather than fentanyl/morphine by non-medically trained (CLS and cross-training aside)? I'm not disagreeing, but opiates have long track record in that setting, while I hadn't heard much about use of ketamine. Are there any studies or case histories relevant to this?


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## Squidward (Jan 19, 2013)

In the case that we did get auto-injectors, still no luck on those yet probably won't see them for awhile, I'd be alright with not being the guy that pulls the trigger on it. It's a safe drug to use with arguably more benefits than opiates, the most celebrated of which being mentioned above (doesn't decrease respiratory drive or heart rate). 

That being said, I don't distro anything out to my guys that they have never seen/ been trained on before.


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## pardus (Jan 19, 2013)

I had a wisdom tooth ripped out as a 40yr old. General anesthesia, Ketamine and an opiate I now forget. I was aware they were working on me but I was having a GREAT time!
I remember being PISSED when I came out of it because I was enjoying it so much.


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## Jerry Barrett (Jan 20, 2013)

Yes in most cases I would chose Ketamine over Morphine and definitely Fentanyl as it doesn't knock out the respiratory drive .. in most cases it will increase BP and respiratory drive. I'll look for some papers but we have been using it on the road in Western Australia for many years now with great success.


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## Jerry Barrett (Jan 20, 2013)

*Title:* Safety and efficacy of intranasal ketamine for acute postoperative pain
*Author/Creator:* Christensen, Kyle ; Rogers, Elizabeth ; Green, Geoff A. ; Hamilton, Douglas A. ; Mermelstein, Fred ; Liao, Edward ;Wright, Curtis ; Carr, Daniel B.
*Subjects:* Intranasal administration ; Ketamine ; Analgesia ; Postoperative pain ; Dental pain
*Is Part Of: *Acute Pain, 2007, Vol.9(4), pp.183-192 [Peer Reviewed Journal] 
*Description: *Background Subanaesthetic doses of ketamine are analgesic. Intranasal administration offers a non-invasive route for systemic drug delivery. We evaluated the safety and analgesic efficacy of intranasal ketamine in treating moderate-to-severe, acute postoperative pain in the molar extraction model. 
Methods Intranasal ketamine (10 mg, 30 mg, and 50 mg) and placebo were evaluated in a randomised, double-blind, single-dose, parallel study in 40 patients undergoing removal of 2–4 impacted third molars. Analgesic efficacy was assessed over a 3 h period following drug administration. Safety was evaluated through adverse event reporting, vital signs, pulse oximetry, nasal assessments, and a standard dissociative side effects questionnaire. 
Results Ketamine delivered intranasally was well tolerated. Statistically significant analgesia, superior to placebo, was observed with the highest dose tested, 50 mg, over a 3 h period. Rapid onset of analgesia was reported (<10 min), and meaningful pain relief was achieved within 15 min of the 50 mg dose. The majority of adverse events were mild/weak and transient. No untoward effects were observed on vital signs, pulse oximetry, and nasal examination. At the doses tested, no significant dissociative effects were evident using the Side Effects Rating Scale for Dissociative Anaesthetics. 
Conclusion Intranasal ketamine may offer a safe, nonopioid, well-tolerated, needle-free analgesic with efficacy in moderate-to-severe acute pain. 
*Language: *English 


*Identifier: **ISSN: *1366-0071 ; *DOI: *10.1016/j.acpain.2007.09.001 
This is a great study that uses IN route, no sharps, no IV access...perfect for any conflict zone...


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## kaja (Jan 20, 2013)

Thanks Jerry!

Regarding ketamine I would be worried about possible psychological /PTSD problems when not used with benzodiazepines.... The idea of being shot in combat and then given ketamine kind of scares the shit out of me...

To clarify- I'm not against ketamine, but just want to play a little devils advocate here to get more informations/opinions for when I'll try to get it approved for field use for me/ our SOPs. For civilian mass-casualty and disaster response the ketamine is our to-go analgetics, but not so much for military/ field use by non-doctor personnel.


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## Jerry Barrett (Jan 20, 2013)

Right on Kaja I can see where you are coming from and understand. I guess with prolonged use of Ketamine I may be worries but for one off analgesic use I would see no problem at all, instead of having a flat casualty you quite often get a helping hand. Ketamine works so very differently than opioid s in so much as it just confuses the brain into thinking that the pain is someother sensation....it doesn't fuck with the CNS too much. A functional casualty in a fire fight is better than a flat one, also if you get heavy handed with the dosing you still maintain the airway!!


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## bublik (Jan 20, 2013)

I really appreciate this thread and input from all b/c I was hesitant to use ketamine early on in my training. I grew increasingly comfortable w/it after a stint at Landstuhl...used it lots since and I think it's a fantastic drug, for many reasons, when used appropriately. I do premedicate w/benzos b/c patient feedback dictates varying experiences.

I took care of one guy that had a horrible, nightmarish experience w/ketamine (major burns, years and years of surgeries) and he specifically asked that I not use ketamine so that was a no brainer. He did fine w/anesthesia and woke up a-ok but there's no way I'd subject him to something that was bad juju for him.

During the same timeframe I took care of 5 or 6 different guys who'd received ketamine ONLY after initial injury and they loved it (one felt like he was in a video game, another thought he was flying, the stories are great when they have a good experience). I premedicate w/benzos but if I was a high speed type and ONLY able to carry one drug it'd be ketamine. Luckily that's not the case but lots more bang for the buck than w/morphine. I can't remember the last time I gave morphine to a patient but I have access to everything else so it'd be last in a controlled setting.

There are those in my world who aren't major ketamine fans but I think it's a fantastic option for field medicine (insert appropriate training and all disclaimer shenanigans here). The only clinical difference I see on a daily basis is that in larger doses (even w/versed) postoperative females tend to cry more  take from that what you will but it hasn't stopped me from using it in smaller doses...you know how we girls are...boohoohoo. No one likes a crying patient in the recovery room, poor form even if the patient doesn't remember it.


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## SPLAT (Apr 4, 2013)

LOVE KETAMINE for trauma sedation / pain management.  Have used it several times in combination with Versed and have never had any re-emergence issues.  Sent it both IV and IM...IM route works surprisingly fast.  I had one patient who's vehicle was hit by a train and he was effectively FUBARed, traumatic crush / leg amp BTK, FX pelvis & femur, hypotensive, screaming in pain, altered and trying to fight with what strength and appendages he had left....Ketamine IV followed by small dose of Versed and it was a nice calm flight.  No additional drop in BP following administration, screaming and thrashing stopped.   I read a study recently which stated even the effects of the ICP increase from Ketamine have been way over blown and there is current literature that suggests Ketamine may be neuroprotective in head injuries.  I will try to find that article again and post it here for the masses.  Good stuff IMO


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## amlove21 (Apr 4, 2013)

SPLAT said:


> *I read a study recently which stated even the effects of the ICP increase from Ketamine have been way over blown and there is current literature that suggests Ketamine may be neuroprotective in head injuries. I will try to find that article again and post it here for the masses. Good stuff IMO*


That would be awesome. I hope you find it. 

I have also been pleasantly surprised with ketamine's effectiveness IM, even in hemodynamically challenged patients.


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## bublik (Apr 4, 2013)

The info from TCCC and Defense Health Board supports use in regard to ICP concerns:

"Ketamine has traditionally been contraindicated in patients with headinjury due to a belief that it
may increase intracranial pressure (ICP).
38
The FDA approved package insert also notes that an increase in intracranial cerebrospinal fluid pressure has been reported after administration of ketamine and advises extreme caution when using ketamine in patients with increased ICP.
35

In vitro and animal studies suggest that ketamine may in fact have neuroprotective properties due to it being an N-methyl-D-aspartate antagonist.
38, 39, 40, 41
Additionally, recent studies suggest thatketamine may be safe for brain injured patients.
38, 42, 43, 44, 45
However, these studies had small sample sizes and primarily examined ketamine administration in combination with other anesthetics or sedatives. Because many of these ketamine studies are limited to procedural sedation in pediatric populations and none address ketamine use in pre-hospital, austere environments, the generalizability to tactical settings is limited. The consensus opinion of the Board members who are subject matter experts in neurosurgery and neurotrauma reaffirmed that the quality of the studies suggesting that ketamine can be used safely in those with head injury is insufficient and that these results are not generalizable to casualties with head injuries. The DHB concludes that this literature contains low-level evidence that may not be applicable, and recommends that until large randomized controlled trials examining the use of ketamine alone demonstrate that ketamine does not increase ICP, ketamine should not be used in patients with significant TBI (penetrating brain injury or head injury with altered level of consciousness)."


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## surgicalcric (Apr 4, 2013)

I was pleasantly happy with its results once I was on a drip.  The initial administration of 100mg IO did little for me though.

Crip


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## TLDR20 (Apr 4, 2013)

surgicalcric said:


> I was pleasantly happy with its results once I was on a drip.  The initial administration of 100mg IO did little for me though.
> 
> Crip



Did you receive Fentanyl or Morphine POI?


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## surgicalcric (Apr 4, 2013)

I received two 800mcg lollipops and 10mg MS IM at the POI that took the edge off however I remember the events from wounding to the OR at Tarin Kowt.


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## bublik (Apr 4, 2013)

Thank you for sharing your experience. If you don't mind me asking, do you know how long were you on a ketamine drip?

As a CRNA I've used it plenty in various settings and routes, yet never needed it myself as I've only ever had a spinal for a lower extremity surgery. The majority of prolonged experience was in the ICU when I was a nurse. I don't hear a lot of negative feedback in general nor do I hear much about longer infusions (other than for complex regional pain syndrome) so I'm curious if you have feedback. Any and all info appreciated.


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## surgicalcric (Apr 4, 2013)

bublik said:


> Thank you for sharing your experience. If you don't mind me asking, do you know how long were you on a ketamine drip?.


 
I was on a propofol and ketamine drip for 9 days.


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## amlove21 (Apr 4, 2013)

surgicalcric said:


> I received two 800mcg lollipops and 10mg MS IM at the POI that took the edge off however I remember the events from wounding to the OR at Tarin Kowt.


I really, really dislike the fentanyl pops. I have never given them to a patient that has said anything BUT "well, it took the edge off, not much though." Just not impressed.


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## SPLAT (Apr 5, 2013)

Good to know...we were looking at the fentanyl pops as an option for pain management POI for SWAT. We do a lot of REMOTE mountain terrain, counter narc ops with long evac times. Looking for a little more than "took the edge off".


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## TLDR20 (Apr 5, 2013)

surgicalcric said:


> I received two 800mcg lollipops and 10mg MS IM at the POI that took the edge off however I remember the events from wounding to the OR at Tarin Kowt.



Did you guys have the intranasal ketamine at that point?


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