How to use ketamine fearlessly for all its indications smacc 2015 no builds

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SMACC Conference Reuben Strayer Ketamine is best known for producing dissociative anesthesia by a unique mechanism where cardio-respiratory function is preserved. It has an extraordinary safety profile that lends itself well to a variety of uses in the emergency department, intensive care, and pre-hospital environments. We will discuss many of these applications, with a focus on the myths and controversies that might discourage emergency clinicians from taking advantage of this remarkable agent.

Salud y medicina

Ketamine: How to Use
it Fearlessly For All its
Indications
reuben j. strayer
@emupdates

Ketamine: How to Use
it Fearlessly For All its
Indications
reuben j. strayer
@emupdates
no disclosures / conﬂicts

the effects of ketamine on the body
hypertension
tachycardia
bronchodilation

ketamine brain continuum
analgesia
recreational
partially
dissociated
dissociated
10 mg
30 mg
50 mg
100 mg

pro
complete analgesia, sedation, amnesia
airway reflexes maintained
cardiorespiratory tone augmented
rapid onset, predictable duration
can be used intramuscularly
unmatched margin of safety
con
hypertension, tachycardia
hypertonicity
hypersalivation
no reversal agent
psychiatric distress
ketamine for procedural sedation
Brown 2008
Chong 2013

ketamine for procedural sedation
anticipate
ketamine brain continuum - be careful with small doses
treat
prevent
pre-induction comfort
pre-induction coaching
psychiatric distress is not a reason not to use ketamine
vs. ketofol Green 2011

ketamine for RSI
partial dissociation and emergence distress not a concern
vs etomidate
can be used in all patients where increase in HR and BP is acceptable
take advantage of the flat part of the brain continuum: dose big
unless obtunded and very hypotensive
the contraindication myths have been debunked
increased ICP
increased IOP
psychiatric disease
Chang 2013
Filanovsky 2010
Himmelseher 2005
Sehdev 2006
Halstead 2012
Drayna 2011
Le Cong 2010
excellent for all hypotensive patients, including trauma
optimal for patients being intubated for asthma or COPD

ketamine for post-intubation sedation
push ketamine, not vecuronium

severe oxygenation
or ventilation deficit?
NIV, KSIyes
no
yes preoxygenate
obtunded, no blood pressure? NoSIyes
resuscitate
time,
cooperation?
no
KSI
double setup
yes
awake intubation
high risk to vomit? yes
RSI
double setup
no
yes
glycopyrrolate
lidocaine
head elevation
NG tube
LMA ventilation if needed
high concern for
difficult laryngoscopy?
RSIno
no
ready with plan B, C, D
apneic?
yes
RSI
tolerates optimal
preoxygenation?
DSInono

abdominal migraine
chronic ischemic pain
atypical odontalgia
phantom pain
postherpetic neuralgia
post-stroke pain
spinal injury pain
TMJ joint arthralgia
intractable headache
ketamine for analgesia
ketamine is a powerful analgesic - 0.15 mg/kg
when opioids are not effective
when opioids are not desired
daily opioid users with chronic pain and some other reason to be in the ED
Bell 2009
Ahern 2013
Fine 1999
Gharaei 2012
Jennings 2011
Richards 2012
Zempsky 2010
Beaudoin 2014
Ding 2014
low back pain
chronic pancreatitis
fibromyalgia
myofascial pain syndrome
complex regional pain syndrome
sickle cell
opioid withdrawal
neuropathic pain
cyclic vomiting
gastroparesis

ketamine for analgesia
ketamine is a powerful analgesic - 0.15 mg/kg
when opioids are not effective
when opioids are not desired
daily opioid users with chronic pain and some other reason to be in the ED
recovered opioid addicts with acute pain
marginal blood pressure or breathing
bolus vs. drip
Bell 2009
Ahern 2013
Fine 1999
Gharaei 2012
Jennings 2011
Richards 2012
Zempsky 2010
Beaudoin 2014
Ding 2014
20 mg over 10 minutes, then
20 mg/hour titrated to effect
not PSA - no monitoring required

ketamine for asthma
Denmark 2006
Goyal 2013
Heshmati 2003
Shlamovitz 2011

ketamine for tranquilization
speed, safety, reliability, IM
increases in HR and BP less than uncontrolled thrashing rage
this is procedural sedation - treat as such
ketamine 500 mg IM x 1
ACEP 2009
Roberts 2001
Burnett 2012

ketamine brain continuum
analgesia
recreational
partially
dissociated
dissociated
10 mg
200 mg
?

use ketamine fearlessly
procedural sedation
airway management
analgesia
asthma
tranquilization
emupdates.com

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1. Ketamine: How to Use it Fearlessly For All its Indications reuben j. strayer @emupdates

2. Ketamine: How to Use it Fearlessly For All its Indications reuben j. strayer @emupdates no disclosures / conﬂicts

4. the effects of ketamine on the body hypertension tachycardia bronchodilation

5. the effects of ketamine on the brain

6. the effects of ketamine on the brain

7. ketamine brain continuum analgesia recreational partially dissociated dissociated 10 mg 30 mg 50 mg 100 mg

8. pro complete analgesia, sedation, amnesia airway reflexes maintained cardiorespiratory tone augmented rapid onset, predictable duration can be used intramuscularly unmatched margin of safety con hypertension, tachycardia hypertonicity hypersalivation no reversal agent psychiatric distress ketamine for procedural sedation Brown 2008 Chong 2013

9. ketamine for procedural sedation anticipate ketamine brain continuum - be careful with small doses treat prevent pre-induction comfort pre-induction coaching psychiatric distress is not a reason not to use ketamine vs. ketofol Green 2011

10. ketamine for RSI partial dissociation and emergence distress not a concern vs etomidate can be used in all patients where increase in HR and BP is acceptable take advantage of the flat part of the brain continuum: dose big unless obtunded and very hypotensive the contraindication myths have been debunked increased ICP increased IOP psychiatric disease Chang 2013 Filanovsky 2010 Himmelseher 2005 Sehdev 2006 Halstead 2012 Drayna 2011 Le Cong 2010 excellent for all hypotensive patients, including trauma optimal for patients being intubated for asthma or COPD

11. ketamine for post-intubation sedation push ketamine, not vecuronium

12. severe oxygenation or ventilation deficit? NIV, KSIyes no yes preoxygenate obtunded, no blood pressure? NoSIyes resuscitate time, cooperation? no KSI double setup yes awake intubation high risk to vomit? yes RSI double setup no yes glycopyrrolate lidocaine head elevation NG tube LMA ventilation if needed high concern for difficult laryngoscopy? RSIno no ready with plan B, C, D apneic? yes RSI tolerates optimal preoxygenation? DSInono

13. abdominal migraine chronic ischemic pain atypical odontalgia phantom pain postherpetic neuralgia post-stroke pain spinal injury pain TMJ joint arthralgia intractable headache ketamine for analgesia ketamine is a powerful analgesic - 0.15 mg/kg when opioids are not effective when opioids are not desired daily opioid users with chronic pain and some other reason to be in the ED Bell 2009 Ahern 2013 Fine 1999 Gharaei 2012 Jennings 2011 Richards 2012 Zempsky 2010 Beaudoin 2014 Ding 2014 low back pain chronic pancreatitis fibromyalgia myofascial pain syndrome complex regional pain syndrome sickle cell opioid withdrawal neuropathic pain cyclic vomiting gastroparesis

14. ketamine for analgesia ketamine is a powerful analgesic - 0.15 mg/kg when opioids are not effective when opioids are not desired daily opioid users with chronic pain and some other reason to be in the ED recovered opioid addicts with acute pain marginal blood pressure or breathing bolus vs. drip Bell 2009 Ahern 2013 Fine 1999 Gharaei 2012 Jennings 2011 Richards 2012 Zempsky 2010 Beaudoin 2014 Ding 2014 20 mg over 10 minutes, then 20 mg/hour titrated to effect not PSA - no monitoring required

15. ketamine for asthma Denmark 2006 Goyal 2013 Heshmati 2003 Shlamovitz 2011

16. ketamine for tranquilization speed, safety, reliability, IM increases in HR and BP less than uncontrolled thrashing rage this is procedural sedation - treat as such ketamine 500 mg IM x 1 ACEP 2009 Roberts 2001 Burnett 2012

17. ketamine brain continuum analgesia recreational partially dissociated dissociated 10 mg 200 mg ?

18. ketamine for suicidality?

19. use ketamine fearlessly procedural sedation airway management analgesia asthma tranquilization emupdates.com

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