Ketamine

[policemedic]

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.

-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.

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.

 

[Red Flag 1]

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

 

[Jerry Barrett]

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!

 

[Squidward]

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

 

[Red Flag 1]

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

 

[Squidward]

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?

 

[policemedic]

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

 

[Dame]

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.

 

[Red Flag 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?

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.

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

 

[Squidward]

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.

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.

 

[Dame]

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.

 

[Red Flag 1]

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

pm inbound.

RF 1

 

[amlove21]

...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.

 

[Red Flag 1]

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

 

[amlove21]

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.

 

[HoosierAnnie]

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

 

[Muppet]

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.

 

[Squidward]

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.

 

[kaja]

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?

 

[Squidward]

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.