Ketamine

amlove21

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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.
 

TLDR20

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

Muppet

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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.
 

LibraryLady

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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
 

Wench

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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.
 

amlove21

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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?

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.

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.
 

TLDR20

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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.
 

policemedic

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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.
 

policemedic

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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.
 

amlove21

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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.
 

Wench

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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 :D) .

"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.
 

amlove21

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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 :D) .


"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.

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.
 

policemedic

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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.

- 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.

-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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