Date post: | 08-Jan-2017 |
Category: |
Health & Medicine |
Upload: | smacc-conference |
View: | 13,764 times |
Download: | 2 times |
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
the effects of ketamine on the brain
the effects of ketamine on the brain
ketamine brain continuum
analgesia
recreational
partially dissociated
dissociated
10 mg
30 mg
50 mg
100 mg
procomplete analgesia, sedation, amnesia airway reflexes maintained cardiorespiratory tone augmented
rapid onset, predictable duration can be used intramuscularly unmatched margin of safety
conhypertension, tachycardia hypertonicity hypersalivation no reversal agent psychiatric distress
ketamine for procedural sedation
Brown 2008 Chong 2013
ketamine for procedural sedation
anticipateketamine brain continuum - be careful with small doses
treat
preventpre-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? NoSIyesresuscitate
time, cooperation?
no
KSI double setup
yes
awake intubation
high risk to vomit? yesRSI
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
?
ketamine for suicidality?
use ketamine fearlessly
procedural sedationairway managementanalgesiaasthmatranquilization
emupdates.com