Low Dose Ketamine for Analgesia in the ED 

This month JC will be looking at the use of ketamine as an analgesic agent in the Emergency Department. As stated in the 2011 ACEP Guidelines “The dissociative agent ketamine has been the single most popular agent to facilitate painful emergency department (ED) procedures in children for nearly 2 decades.”  Many of us have had our first experiences with ketamine when working with our pediatric EM colleagues. One of my earlier experiences was repairing a large tongue laceration whilst parents looked on at their happy camper in amazement.  In adult EM, there have been a host of articles (mostly observational) that suggest other areas of efficacy. A recent meta-analysis demonstrated efficacy in combination with Propofol (Ketofol), where incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower when compared to each medication separately.  There have been additional studies regarding ketamine in severe asthma though a Cochrane review refutes proven efficacy in kids. Interest in ketamine as an adjunct in the acutely agitated patient in the EMS environment has been published. Other areas of interest include convulsive status  and those with chronic pain syndromes. Ketamine is an important adjunct in the ED and every EM physician should have a high comfort level with its use. Does its use as an analgesic agent, when compared to usual narcotic agents offer any benefits? Should make for some interesting discussion.  

 Motov S. et al., Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial Ann Emerg Med. 2015 Sep;66(3):222-229   Appraisal

Beaudoin FL et al, Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial. Acad Emerg Med. 2014 Nov;21(11):1193-202.  Appraisal

Ahern TL, et al, The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med. 2015 Feb;33(2):197-201.  Appraisal

Green SM et al., Clinical practice guideline for emergency department ketamine dissociative sedation: Ann Emerg Med. 2011 May;57(5):449-61.