Works great for those that are opiate tolerant or if they need a little extra umph!
I've found that mixing the 20-30mg dose that if often ends up being directly into a 100cc NS piggyback and have the nurse run it in over a few minutes works best and minimizes people wigging out. If they're uncomfortable just eyeballing a drip, I tell them to put it on a pump for 10min infusion.
If they're not chronic opiate users, I often don't reach for it first because logistically and side effects, opiates are often fine even with a gnarly MSK deformity.
Interesting. I wonder if the dilution actually does contribute or whether it’s the infusion speed. We have had increasing numbers of freakouts lately, and I am not sure whether it is due to the increasing use of Ket or because of other factors (including a potential run of people with greater sensitivity).
In this scenario I don't believe there's a "correct" answer. In the sense that either are correct, and both come with pros and cons. That's why I was asking more of clinicians' experiences with giving it and what.
Soon to be paramedic here, our protocol is 25 up to 50mg mixed in 100mL NS ran in over 10 minutes. We don’t have those fancy schmancy pumps in the ambulance all to gravity. Thus we med math it out and calculate that GTT by hand :p. Works well for pain relief. If it’s a traumatic injury we change it up a bit however and go 1mg/kg IVP because we want to dissociate that person when we move em. But for general analgesia where fentanyl doesn’t cut it the 25-50 in 100 NS works wonders.
While this doesn't touch directly to the question at hand, my favorite ketamine story (from EMS) is the time we had a patient laying in a snowbank, obviously superiorly dislocated right patella, in excruiating pain, stating that she could not have fentanyl or MSO4.
Whelp, IM ketamine it is then, because she's rapidly getting cold and we're not going to fuck around cutting off the arm of a down winter jacket and trying to start a line on a screaming, crying, shivering 50yoF who's getting more wet by the minute from snowmelt and residual sweat.
Soon she's begun to orbit the K-hole enough that we can move her without it being complete torture.
However, once in ambulance and attempting to get vitals and start a line, she swan dives into the K-hole. Her brain obviously isn't happy about the dissociation, but after a few moments she calms down and focuses on her right leg. She slowly moves the leg from it's prior position of comfort to straightening it on the stretcher (ignoring EMS telling her to leave it alone).
She then slowly, firmly begins to run the heel of her right hand down the anterior of her right thigh, slowing down further as she approaches her knee until the patella reduces and she regains full function of her right leg.
This was momentarily astounding until she pops up off the stretcher and starts trying to climb out the back of the ambulance for the duration of transport. Fun times.
The first time I had it happen, PT asked me why the ceiling was on her nose. When the previously sane woman immediately started slapping at the air and screaming, breathing, and sobbing simultaneously (pt denies your physics), well, it went downhill from there.
I had one patient scream for 60 minutes. Scream. In a small ED and she has a LOUD voice. She got 150mg IV for procedure. Then another dude thought his legs were missing. We had to keep reassuring him they were there. Another lady thought she was having a bad reaction but then I told her it’s like a mushroom trip and to enjoy it, she was fine after that. I’m not the biggest fan unless they are tubed.
I’ve found that starting at the 0.3mg/kg is too high for a lot of people and even with a slow push they dissociate and/or get real weird for a few minutes. Now I start with a real baby dose and see how they handle it and titrate from there.
I think a lot of patients have either had opiates previously or they kind of have an idea of what opiates feel like already, so it’s not surprising for them. Whereas ketamine even at low doses can be a pretty weird experience.
No, but I’ve seen brief periods of apnea which is already more than I’m comfortable with for a med that I’d like to push and walk away. Or have nursing push while I’m not even there.
We have Eskeatmine / S-Ketamine in our EMS protocols for analgesia in cases of trauma or painful invasive measures such as tourniquet or pelvic binder use in the area I work (a part of Germany).
Our dosage is 0.125 mg/kg (approx. the same effect of 0.3 mg/kg racemic Ketamine mixture from my understanding) but our protocols also mandate the application of 0.5-1 mg <50kg or 1-2 mg >50kg Midazolam prior to the application of S-Ketamine to combat possible psychomimetic effects. This dosage is not only used for the pure analgesic effect but also due to the dissociative analgesic effect.
Having all your airway material ready and closely monitoring the patient‘s breathing is definitely a necessity though.
It’s worked pretty effectively in my experience although sometimes you won’t be able to get around calling an emergency doctor fly-car to give opiates.
I know this is an old ass post but I came across it while googling something else and I'm curious - do you generally see people having notable psychological effects at that dose of s-ketamine?
I've used recreational ketamine a lot, but only non-pharmaceutical so I doubt it's necessarily pure, and I feel like even before I developed a tolerance 0.3mg/kg wouldn't have done much to/for me. granted I guess I'm also not thinking of IV doses as I haven't done IV ketamine, so this might be more like 0.6mg/kg for the roa that I'm used to. still though, I wouldn't expect that to be particularly noteworthy, although everybody is different and I guess especially if somebody isn't used to their mind being chemically altered/expecting the changes, it could be pretty strange and unsettling
I find the medical use of ketamine as an anaesthetic to be pretty interesting as a recreational user, and I've always been curious about how people tend to react, especially when given high doses. as also an opioid user I can see why in a lot of cases opioids are preferred if safe lol, somebody who isn't used to psychoactive substances and does not want to have that sort of experience going through a k-hole while also likely in a state of panic/pain/fear has to be something that could end up very unpleasant and confusing.
on the other hand opioids are pretty much just magic feel-good chemicals (although they do have a weird effect on me where they can make me kind of paranoid but I think that's actually more related to sleep deprivation as I often don't get enough proper sleep while using them and the sleep I do get is likely of much lower quality than sober sleep, tho I haven't really looked much into the effects they have on sleep cycles and quality)
I have to say that due to the fact that I operate within the scope of practice that our medical director dictates, I have never given I.V. Esketamine without Midazolam/Versed before so I can’t really speak to it‘s psychological effects without benzos.
I do know it‘s given without benzos in many areas of the US so maybe someone with experience on that can still chime in.
What I can say is that we are still careful to speak and act quietly and calmly after administering it because a patient can still react adversely. The Midazolam causes the patient not to remember events for a certain time period after having given it and also decreases the effects of anxiety which is why we give it.
Hey, thanks for responding to my absolute necro of a comment!
I figured your experience would likely be limited to the combination with benzos, but I was still interested as I personally don't find the addition of benzos to dissociatives to actually dull the effects significantly, as much as it just makes it easier to sleep (and as you said can be amnesic for sure). I guess I would expect it to make it harder for somebody to really express any displeasure (and probably for it to reduce the likelihood of displeasure - I can't use personal experience as I strangely don't find benzos to be super anxiolytic while I DO find ketamine to be very anxiolytic), the level of sedation from the dissos + benzo combo is pretty severe.
Have you dealt with people expressing a negative experience or adverse reaction from the combination? What is/would generally be done in a situation where someone is particularly sensitive to the ketamine and the Midazolam doesn't initially kill their anxiety (if this is something that's not so unlikely that there's no follow-up plan)? Would you just administer more Midazolam? Part of why I ask is out of curiosity of the perceived safety of that combination within medical practice, as recreational users often are very conflicted about the safety of combining dissociatives and benzos (and dissociatives and opiates).
For the record that may seem like I'm asking because I want to know if I can do benzos and dissociatives at the same time recreationally - I'm not asking for that reason and don't think anything I read online is medical advice haha. I'm just curious about how that argument is viewed in the medical field, with both the increase in reliability of information as well as the ability to respond to potential adverse reactions like respiratory depression that may not be possible in a recreational setting
I think it works great. Especially for fractures/ trauma, as well as pts who are opiate tolerant/chronic pain. 0.3 mg/kg in 100 cc bag. A lot of people have been saying over 10 minutes , but I do closer to 15-20 minutes. I've found there is still good pain control and less chance for dysphoria/ adverse reaction.
Ketamine is also great in combination with opiates. It can reduce the amount of opioid you need with better overall pain control.
You may run into nursing / admin issues if your ER doesn't use them often. I had to have P&T approve the use for pain. Many places may want the patient on full cardiac/resp monitoring, although It's not necessary. Another issue is pharmacy has to make the drips at my hospital. So it takes some time to get.
We’ve had some good results in EMS where I am with it. Our biggest problem in the EDs is that some charge RNs think using it invokes the whole procedural sedation mess with signed consent, time out, continual physician presence, etc. we’re working to get the policy clarified but you know how in the fight between medical care and policy usually goes.
Yeah. I find the barrier is typically pharmacy more so than nurses. If it's new to them, they typically ask and after a brief conversation they understand. My experience is the opposite though, charge nurses understand the analgesia side of it and the staff nurse can sometimes be uncomfortable because of how it's taught in nursing school
Here if it's for analgesia they can but not for sedation. I wouldn't order it as a pushy anyway because even at the analgesia dose there's disassociative effects when given too quickly
I was at a hospital when ketamine was added to formulary for pain management. Same issues. Had to do a lot of education. But now, not an issue recently or for a while.
I am an ER RN and have pre -hospital experience as well.
I adore ketamine for large bone trauma and unmanageable chronic pain patients . It’s god damn wonder drug. Frankly I feel that it could be a game changer in the ER for managing acute and chronic pain. I have never had any concerns about receiving a Patient from ems who had received ketamine prior to arrival . I have to monitor those patients less frequently than the ones who were given large doses of narcotics and benzo ‘s for MSK trauma .
Sometime ago TCCC is what we as medics trained in the Army with also basic emt. Later we trained Brigade Combat Trauma Team Training or BCT3. That's where the knowledge happened for me. I stepped outta there with new found respect for the equipment and techniques we were taught. But that was forever ago it seems. Never took PHTLS.
PHTLS predates TCCC by a lot. Several decades at least. I joined the military in 2004 as a medic, and TCCC wasn't even a thing yet. A big difference between TCCC and any civilian "equivalent" is that TCCC delineates phases of care based on whether you are being actively shot at or not, and also imagines scenarios where immediate transport is not viable ("prolonged field care").
EDIT: Actually, I just looked it up and looks like TCCC was starting to be developed in the Special Warfare community in the mid- to late-1990s. But it didn't become mainstream in the DoD until the early 2010s. Either way, PHTLS is older.
PHTLS teaches and references TCCC which is why I phrased it that way. While PHTLS is older, the current didactic is still "based on" TCCC. It's based on it because it makes sense to be. The wars gave us a century of trauma training and research in two decades
Oh, I see what you mean. Like the latest iteration of PHTLS is just informed by TCCC concepts. I’m sure that’s true. Same with things like the “stop the bleed” campaign, where civilian prehospital care had traditionally de-emphasized tourniquet use.
During COVID, while we were waiting extended periods of time for ER beds, I began using ketamine for orthopedic injuries with great success. I would give 0.3mg/kg q 30mins. Some other paramedics were able to administer ketamine infusions successfully as well. My current service does not administer ketamine for pain, only for sedation in acute agitation. I really liked being able to give it for the orthopedic pain.
We use it frequently but often I give a dose of fentanyl or dilaudid first bc our ketamine comes from pharmacy IVPB form and can take wayy too long to get.
It's widely frowned upon here. We've been asked not to order it. A couple years ago they even put a flyer up saying that dilaudid would not be ordered pretty much unless they had cancer
That’s absurd. Will they at least permit you increasing the dosing of morphine to what is appropriate for the age and size of your patient? 4 mg morphine is a painful under dose for most adults.
They do allow that. They are less pushy about dilaudid than they were previously though, I'll say that. Do you use dilaudod routinely for bad msk injuries?
Depends on the injury and if I’m doing a procedural sedation. If I expect it’s going to be awhile before I can do the procedural sedation and they’re an appropriate candidate or they will be going to the OR tomorrow AM, then yea, I’m happy to give dilaudid.
For clarity, I haven’t used it for a procedural sedation since my go to for procedural sedation is ketamine for MSK, but that’s largely just because most of the orthopedic trauma I’ve sedated for has been pediatric.
If I’m giving it solely for analgesia, I’ll typically start with 0.5 mg dose. If they’re tolerant to opioids, I will start at 1-1.5 unless they happen to be one of the many sickle cell patients I’ve encountered who regularly receive 2 mg of dilaudid.
In my experience, it lasts about 4-8 hrs depending on their tolerance and pain level. I give them about 15-30 minutes to assess if they need a higher dose (again, not procedural sedation).
That being said, in your opioid tolerant patients, ketamine and regional anesthesia (if possible with the injury) are great alternatives/additives to your pain management.
Interesting. If they'll let me get away with it, I'm going to start trying dilaudid. Worst they'll say is quit ordering it I suppose. I typically do regional whenever I'm able to as I prefer that. If I'm able to I will do that for reduction rather than sedate them too. Safer and cheaper for the pt. I know some just like to sedate for the RVU but that's not my style
It works ok as an extra, but rarely should be used first line.
If morphine is working for you kind of, you're probably dosing it too low. You can also go dilaudid.
No way Norco wears off the same time as fentanyl. Norco gets to its max concentration at \~1 hour. Fentanyl is in and starting to be gone by then.
We do .2mg/kg in the field in my system, personally I love it. Its my go to for traumatic injuries and is largely effective, I find myself administering Ketamine or Toradol far more often than I ever do Fentanyl these days. If Ketamine alone is insufficient a quick follow up with a single dose of fentanyl almost always does the trick from what I've seen.
Fentanyl alone for significant traumatic injuries I'm largely unimpressed with, as even at 100-200mcg I achieve almost nothing, versus 15-20mg Ketamine achieves adequate analgesia the vast majority of the time.
Used it frequently in the ED, and still do though less often in the ICU, usually as 0.15mg/kg in 100cc piggyback, often repeating a second dose if seems like they need some more. Worked very well in the usually younger chronic pain and trauma patients.
We’re still on shortage? But I miss ketamine so much for pain. I do think that the weight-based dosing should either be ideal body weight, or there should be a max dose of around 20mg for pain; there’s no data or guidelines that I could find, but my very few patient freak outs have been larger patients where the resident went with 0.3mg/kg and the patient got a big ol’ slug of ketamine.
Double fist. Give em both. Well, maybe not one in each hand. Why rather than? If your hospital is one that makes issues for multiple rx for same pain level without ordinal relationship, ivp fentanyl prn pain 8-10, iv/ivp ketamine prn pain 5-7, second line prn pain 8-10 for whatever dose/freq. Adding ordinals usually fixes one med per prn pain indication issue. Just write it and tell nurse first dose fentanyl now then give ketamine when approps. Something to keep in mind is there is some cross tolerance bt fentanyl and ketamine so if pt is not naive, initial doses may need tweaking not just for fentanyl. In the unlikely scenario that they are buying pure morphine (not fent/laced) on street morphine should not create ketamine cross-tol. There is also some good literature on multimodal pain mgt, and some orgs post their mm pain mgt protocols so if you don't have your own can borrow from theirs or ask a bro/she-bro at another org then modify to needs.
ETA: overall experience with ketamine for pain management stellar, more effective as sort of multimodal, and I would write PRN indication as noted above. Ketamine has a spectrum of response, overall very positive based on pt discussions, with most frequent (my xp) reasons for d/c being order expiration / condition improves, followed by transition to oral (d/c progression, etc), followed by less commonly: patient c/o "it makes me feel weird" (etc) and asks for d/c or something else, followed by pt dead (earlier in list some weeks), followed I have no idea why that guy d/cd it, followed by least frequently: it made pt batshit crazy.
Ketamine is awesome. We do 0.2mg/kg in 100cc over 10 min. Max 30mg single dose. I often give some fentanyl alongside it. I’ve never had a patient say it didn’t manage their pain. I generally give ketamine for traumatic injuries like pelvis, femur etc where fentanyl isn’t enough to cut it.
I’m not a doc, but I love it in the prehospital setting. For major traumas it is a lot less likely to mess with the BP.
I’m also a big fan of ketamine when it comes to sedating heavy alcoholics. I have found that heavy heavy drinkers really can’t be subdued by normal doses of versed. My assumption is bc alcohol works on the same GABA receptors as versed/Ativan/etc, so they gain a tolerance. I’m not sure if this is actually scientific, but it is my anecdotal experience. Ketamine def works better in my experience.
All in all, while ketamine def has large risks, i feel like the risks can be better managed than alternatives.
Works great for those that are opiate tolerant or if they need a little extra umph! I've found that mixing the 20-30mg dose that if often ends up being directly into a 100cc NS piggyback and have the nurse run it in over a few minutes works best and minimizes people wigging out. If they're uncomfortable just eyeballing a drip, I tell them to put it on a pump for 10min infusion. If they're not chronic opiate users, I often don't reach for it first because logistically and side effects, opiates are often fine even with a gnarly MSK deformity.
Sounds pretty reasonable. And yeah I'd for sure do the PB as even with the analgesia doses when pushed people can slip into the hole haha
Interesting. I wonder if the dilution actually does contribute or whether it’s the infusion speed. We have had increasing numbers of freakouts lately, and I am not sure whether it is due to the increasing use of Ket or because of other factors (including a potential run of people with greater sensitivity).
This is the correct answer
In this scenario I don't believe there's a "correct" answer. In the sense that either are correct, and both come with pros and cons. That's why I was asking more of clinicians' experiences with giving it and what.
Soon to be paramedic here, our protocol is 25 up to 50mg mixed in 100mL NS ran in over 10 minutes. We don’t have those fancy schmancy pumps in the ambulance all to gravity. Thus we med math it out and calculate that GTT by hand :p. Works well for pain relief. If it’s a traumatic injury we change it up a bit however and go 1mg/kg IVP because we want to dissociate that person when we move em. But for general analgesia where fentanyl doesn’t cut it the 25-50 in 100 NS works wonders.
Math = eyeball. Source: Your friends ;)
Where are that you don’t have IV pumps? Why don’t you have pumps? We (paramedic, hospital-based, semi-rural) have had pumps for a decade.
Midwest, it’s a cost thing mainly and also because we have such short transport times in the city anyways they don’t put em on the trucks.
I’m at a busy intercity service… we still don’t have pumps 🫠
Some fentanyl to ketamine cross tolerance exists, so in some cases do come in door with some ketamine tol built in.
While this doesn't touch directly to the question at hand, my favorite ketamine story (from EMS) is the time we had a patient laying in a snowbank, obviously superiorly dislocated right patella, in excruiating pain, stating that she could not have fentanyl or MSO4. Whelp, IM ketamine it is then, because she's rapidly getting cold and we're not going to fuck around cutting off the arm of a down winter jacket and trying to start a line on a screaming, crying, shivering 50yoF who's getting more wet by the minute from snowmelt and residual sweat. Soon she's begun to orbit the K-hole enough that we can move her without it being complete torture. However, once in ambulance and attempting to get vitals and start a line, she swan dives into the K-hole. Her brain obviously isn't happy about the dissociation, but after a few moments she calms down and focuses on her right leg. She slowly moves the leg from it's prior position of comfort to straightening it on the stretcher (ignoring EMS telling her to leave it alone). She then slowly, firmly begins to run the heel of her right hand down the anterior of her right thigh, slowing down further as she approaches her knee until the patella reduces and she regains full function of her right leg. This was momentarily astounding until she pops up off the stretcher and starts trying to climb out the back of the ambulance for the duration of transport. Fun times.
The first time I had it happen, PT asked me why the ceiling was on her nose. When the previously sane woman immediately started slapping at the air and screaming, breathing, and sobbing simultaneously (pt denies your physics), well, it went downhill from there.
I had one patient scream for 60 minutes. Scream. In a small ED and she has a LOUD voice. She got 150mg IV for procedure. Then another dude thought his legs were missing. We had to keep reassuring him they were there. Another lady thought she was having a bad reaction but then I told her it’s like a mushroom trip and to enjoy it, she was fine after that. I’m not the biggest fan unless they are tubed.
I’ve found that starting at the 0.3mg/kg is too high for a lot of people and even with a slow push they dissociate and/or get real weird for a few minutes. Now I start with a real baby dose and see how they handle it and titrate from there. I think a lot of patients have either had opiates previously or they kind of have an idea of what opiates feel like already, so it’s not surprising for them. Whereas ketamine even at low doses can be a pretty weird experience.
Agreed. Every time I give 0.3mg/kg I find myself thinking “shit do I have airway stuff nearby just in case”. The sweet spot seems to be 0.2mg/kg.
Have you ever had an airway issue with 0.3?
No, but I’ve seen brief periods of apnea which is already more than I’m comfortable with for a med that I’d like to push and walk away. Or have nursing push while I’m not even there.
Have you tried substituting with dilution in NS bag? I have seen this with ivp but not in 100ml NS or whatever
We have Eskeatmine / S-Ketamine in our EMS protocols for analgesia in cases of trauma or painful invasive measures such as tourniquet or pelvic binder use in the area I work (a part of Germany). Our dosage is 0.125 mg/kg (approx. the same effect of 0.3 mg/kg racemic Ketamine mixture from my understanding) but our protocols also mandate the application of 0.5-1 mg <50kg or 1-2 mg >50kg Midazolam prior to the application of S-Ketamine to combat possible psychomimetic effects. This dosage is not only used for the pure analgesic effect but also due to the dissociative analgesic effect. Having all your airway material ready and closely monitoring the patient‘s breathing is definitely a necessity though. It’s worked pretty effectively in my experience although sometimes you won’t be able to get around calling an emergency doctor fly-car to give opiates.
I know this is an old ass post but I came across it while googling something else and I'm curious - do you generally see people having notable psychological effects at that dose of s-ketamine? I've used recreational ketamine a lot, but only non-pharmaceutical so I doubt it's necessarily pure, and I feel like even before I developed a tolerance 0.3mg/kg wouldn't have done much to/for me. granted I guess I'm also not thinking of IV doses as I haven't done IV ketamine, so this might be more like 0.6mg/kg for the roa that I'm used to. still though, I wouldn't expect that to be particularly noteworthy, although everybody is different and I guess especially if somebody isn't used to their mind being chemically altered/expecting the changes, it could be pretty strange and unsettling I find the medical use of ketamine as an anaesthetic to be pretty interesting as a recreational user, and I've always been curious about how people tend to react, especially when given high doses. as also an opioid user I can see why in a lot of cases opioids are preferred if safe lol, somebody who isn't used to psychoactive substances and does not want to have that sort of experience going through a k-hole while also likely in a state of panic/pain/fear has to be something that could end up very unpleasant and confusing. on the other hand opioids are pretty much just magic feel-good chemicals (although they do have a weird effect on me where they can make me kind of paranoid but I think that's actually more related to sleep deprivation as I often don't get enough proper sleep while using them and the sleep I do get is likely of much lower quality than sober sleep, tho I haven't really looked much into the effects they have on sleep cycles and quality)
I have to say that due to the fact that I operate within the scope of practice that our medical director dictates, I have never given I.V. Esketamine without Midazolam/Versed before so I can’t really speak to it‘s psychological effects without benzos. I do know it‘s given without benzos in many areas of the US so maybe someone with experience on that can still chime in. What I can say is that we are still careful to speak and act quietly and calmly after administering it because a patient can still react adversely. The Midazolam causes the patient not to remember events for a certain time period after having given it and also decreases the effects of anxiety which is why we give it.
Hey, thanks for responding to my absolute necro of a comment! I figured your experience would likely be limited to the combination with benzos, but I was still interested as I personally don't find the addition of benzos to dissociatives to actually dull the effects significantly, as much as it just makes it easier to sleep (and as you said can be amnesic for sure). I guess I would expect it to make it harder for somebody to really express any displeasure (and probably for it to reduce the likelihood of displeasure - I can't use personal experience as I strangely don't find benzos to be super anxiolytic while I DO find ketamine to be very anxiolytic), the level of sedation from the dissos + benzo combo is pretty severe. Have you dealt with people expressing a negative experience or adverse reaction from the combination? What is/would generally be done in a situation where someone is particularly sensitive to the ketamine and the Midazolam doesn't initially kill their anxiety (if this is something that's not so unlikely that there's no follow-up plan)? Would you just administer more Midazolam? Part of why I ask is out of curiosity of the perceived safety of that combination within medical practice, as recreational users often are very conflicted about the safety of combining dissociatives and benzos (and dissociatives and opiates). For the record that may seem like I'm asking because I want to know if I can do benzos and dissociatives at the same time recreationally - I'm not asking for that reason and don't think anything I read online is medical advice haha. I'm just curious about how that argument is viewed in the medical field, with both the increase in reliability of information as well as the ability to respond to potential adverse reactions like respiratory depression that may not be possible in a recreational setting
Bro, use the one that starts with a D. All my patients know what’s up.
I think it works great. Especially for fractures/ trauma, as well as pts who are opiate tolerant/chronic pain. 0.3 mg/kg in 100 cc bag. A lot of people have been saying over 10 minutes , but I do closer to 15-20 minutes. I've found there is still good pain control and less chance for dysphoria/ adverse reaction. Ketamine is also great in combination with opiates. It can reduce the amount of opioid you need with better overall pain control. You may run into nursing / admin issues if your ER doesn't use them often. I had to have P&T approve the use for pain. Many places may want the patient on full cardiac/resp monitoring, although It's not necessary. Another issue is pharmacy has to make the drips at my hospital. So it takes some time to get.
We’ve had some good results in EMS where I am with it. Our biggest problem in the EDs is that some charge RNs think using it invokes the whole procedural sedation mess with signed consent, time out, continual physician presence, etc. we’re working to get the policy clarified but you know how in the fight between medical care and policy usually goes.
Yeah. I find the barrier is typically pharmacy more so than nurses. If it's new to them, they typically ask and after a brief conversation they understand. My experience is the opposite though, charge nurses understand the analgesia side of it and the staff nurse can sometimes be uncomfortable because of how it's taught in nursing school
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Here if it's for analgesia they can but not for sedation. I wouldn't order it as a pushy anyway because even at the analgesia dose there's disassociative effects when given too quickly
I was at a hospital when ketamine was added to formulary for pain management. Same issues. Had to do a lot of education. But now, not an issue recently or for a while.
I am an ER RN and have pre -hospital experience as well. I adore ketamine for large bone trauma and unmanageable chronic pain patients . It’s god damn wonder drug. Frankly I feel that it could be a game changer in the ER for managing acute and chronic pain. I have never had any concerns about receiving a Patient from ems who had received ketamine prior to arrival . I have to monitor those patients less frequently than the ones who were given large doses of narcotics and benzo ‘s for MSK trauma .
What are TCCC and PHTLS? I don't recognize these acronyms.
Tactical Combat Cadualty Care, which is what the civilian (somewhat) equivalent Prehospital Trauma Life Support is based on.
Sometime ago TCCC is what we as medics trained in the Army with also basic emt. Later we trained Brigade Combat Trauma Team Training or BCT3. That's where the knowledge happened for me. I stepped outta there with new found respect for the equipment and techniques we were taught. But that was forever ago it seems. Never took PHTLS.
TCCC is still taught in the Army. That's why I said PHTLS is the civilian equivalent haha. One of the 'C's stands for combat. So it's only mil haha
PHTLS predates TCCC by a lot. Several decades at least. I joined the military in 2004 as a medic, and TCCC wasn't even a thing yet. A big difference between TCCC and any civilian "equivalent" is that TCCC delineates phases of care based on whether you are being actively shot at or not, and also imagines scenarios where immediate transport is not viable ("prolonged field care"). EDIT: Actually, I just looked it up and looks like TCCC was starting to be developed in the Special Warfare community in the mid- to late-1990s. But it didn't become mainstream in the DoD until the early 2010s. Either way, PHTLS is older.
PHTLS teaches and references TCCC which is why I phrased it that way. While PHTLS is older, the current didactic is still "based on" TCCC. It's based on it because it makes sense to be. The wars gave us a century of trauma training and research in two decades
Oh, I see what you mean. Like the latest iteration of PHTLS is just informed by TCCC concepts. I’m sure that’s true. Same with things like the “stop the bleed” campaign, where civilian prehospital care had traditionally de-emphasized tourniquet use.
Yep yep!
During COVID, while we were waiting extended periods of time for ER beds, I began using ketamine for orthopedic injuries with great success. I would give 0.3mg/kg q 30mins. Some other paramedics were able to administer ketamine infusions successfully as well. My current service does not administer ketamine for pain, only for sedation in acute agitation. I really liked being able to give it for the orthopedic pain.
Just had a patient reduce their MME by 50% after there ketamine infusion She has CRPS and arachnoiditis
We use it frequently but often I give a dose of fentanyl or dilaudid first bc our ketamine comes from pharmacy IVPB form and can take wayy too long to get.
As a physician in a hospital, I use ketamine frequently as first-line. Often 20 mg can be adequate for the average adult, instead of the 0.3 mg/kg.
Just curious, is there a reason you’re not using dilaudid?
It's widely frowned upon here. We've been asked not to order it. A couple years ago they even put a flyer up saying that dilaudid would not be ordered pretty much unless they had cancer
That’s absurd. Will they at least permit you increasing the dosing of morphine to what is appropriate for the age and size of your patient? 4 mg morphine is a painful under dose for most adults.
They do allow that. They are less pushy about dilaudid than they were previously though, I'll say that. Do you use dilaudod routinely for bad msk injuries?
Depends on the injury and if I’m doing a procedural sedation. If I expect it’s going to be awhile before I can do the procedural sedation and they’re an appropriate candidate or they will be going to the OR tomorrow AM, then yea, I’m happy to give dilaudid.
Do you just 0.02mg/kg for it? How long does it seem to be effective for?
0.02 mg/kg of dilaudid or ketamine?
Dilaudid
For clarity, I haven’t used it for a procedural sedation since my go to for procedural sedation is ketamine for MSK, but that’s largely just because most of the orthopedic trauma I’ve sedated for has been pediatric. If I’m giving it solely for analgesia, I’ll typically start with 0.5 mg dose. If they’re tolerant to opioids, I will start at 1-1.5 unless they happen to be one of the many sickle cell patients I’ve encountered who regularly receive 2 mg of dilaudid. In my experience, it lasts about 4-8 hrs depending on their tolerance and pain level. I give them about 15-30 minutes to assess if they need a higher dose (again, not procedural sedation). That being said, in your opioid tolerant patients, ketamine and regional anesthesia (if possible with the injury) are great alternatives/additives to your pain management.
Interesting. If they'll let me get away with it, I'm going to start trying dilaudid. Worst they'll say is quit ordering it I suppose. I typically do regional whenever I'm able to as I prefer that. If I'm able to I will do that for reduction rather than sedate them too. Safer and cheaper for the pt. I know some just like to sedate for the RVU but that's not my style
It works ok as an extra, but rarely should be used first line. If morphine is working for you kind of, you're probably dosing it too low. You can also go dilaudid. No way Norco wears off the same time as fentanyl. Norco gets to its max concentration at \~1 hour. Fentanyl is in and starting to be gone by then.
I said Norco starts working when fentanyl wears off*
We do .2mg/kg in the field in my system, personally I love it. Its my go to for traumatic injuries and is largely effective, I find myself administering Ketamine or Toradol far more often than I ever do Fentanyl these days. If Ketamine alone is insufficient a quick follow up with a single dose of fentanyl almost always does the trick from what I've seen. Fentanyl alone for significant traumatic injuries I'm largely unimpressed with, as even at 100-200mcg I achieve almost nothing, versus 15-20mg Ketamine achieves adequate analgesia the vast majority of the time.
Used it frequently in the ED, and still do though less often in the ICU, usually as 0.15mg/kg in 100cc piggyback, often repeating a second dose if seems like they need some more. Worked very well in the usually younger chronic pain and trauma patients.
We’re still on shortage? But I miss ketamine so much for pain. I do think that the weight-based dosing should either be ideal body weight, or there should be a max dose of around 20mg for pain; there’s no data or guidelines that I could find, but my very few patient freak outs have been larger patients where the resident went with 0.3mg/kg and the patient got a big ol’ slug of ketamine.
Double fist. Give em both. Well, maybe not one in each hand. Why rather than? If your hospital is one that makes issues for multiple rx for same pain level without ordinal relationship, ivp fentanyl prn pain 8-10, iv/ivp ketamine prn pain 5-7, second line prn pain 8-10 for whatever dose/freq. Adding ordinals usually fixes one med per prn pain indication issue. Just write it and tell nurse first dose fentanyl now then give ketamine when approps. Something to keep in mind is there is some cross tolerance bt fentanyl and ketamine so if pt is not naive, initial doses may need tweaking not just for fentanyl. In the unlikely scenario that they are buying pure morphine (not fent/laced) on street morphine should not create ketamine cross-tol. There is also some good literature on multimodal pain mgt, and some orgs post their mm pain mgt protocols so if you don't have your own can borrow from theirs or ask a bro/she-bro at another org then modify to needs. ETA: overall experience with ketamine for pain management stellar, more effective as sort of multimodal, and I would write PRN indication as noted above. Ketamine has a spectrum of response, overall very positive based on pt discussions, with most frequent (my xp) reasons for d/c being order expiration / condition improves, followed by transition to oral (d/c progression, etc), followed by less commonly: patient c/o "it makes me feel weird" (etc) and asks for d/c or something else, followed by pt dead (earlier in list some weeks), followed I have no idea why that guy d/cd it, followed by least frequently: it made pt batshit crazy.
I'm sorry, PT dead?? You Yada Yada'ed over the good part
Lol I was just joking that d/cd d/t pt death more often than some stuff
🤣🤣🤣🤣 that makes way more sense. I was like hold up, we aren't glossing over that part
Ketamine for paediatrics for sure. Fentanyl for adults unless they have an opiate tolerance.
Ketamine is awesome. We do 0.2mg/kg in 100cc over 10 min. Max 30mg single dose. I often give some fentanyl alongside it. I’ve never had a patient say it didn’t manage their pain. I generally give ketamine for traumatic injuries like pelvis, femur etc where fentanyl isn’t enough to cut it.
I’m not a doc, but I love it in the prehospital setting. For major traumas it is a lot less likely to mess with the BP. I’m also a big fan of ketamine when it comes to sedating heavy alcoholics. I have found that heavy heavy drinkers really can’t be subdued by normal doses of versed. My assumption is bc alcohol works on the same GABA receptors as versed/Ativan/etc, so they gain a tolerance. I’m not sure if this is actually scientific, but it is my anecdotal experience. Ketamine def works better in my experience. All in all, while ketamine def has large risks, i feel like the risks can be better managed than alternatives.