Reuben Strayer, MD
Courtesy of Reuben Strayer, MD

Emergency Medicine Physician who works in New York City

Author of emupdates.com

One of the authors of painandspa.org

Twitter @emupdates

Created the phrase "ketamine brain continuum"

No financial disclosure

 

 
Ready to continue your Special K Trip?
Today's episode is Part 2 out of a 3-part series and will cover the use of ketamine for procedural sedation and intubations in the ED with Reuben Strayer, MD.

If you didn't listen to Reuben talk about ketamine, the safety measures of ketamine, or confused by this graphic with different dosing - go back and listen to Episode 7 for Part 1 where this is explained in detail.

 
Ketamine for Procedural Sedation and Analgesia (PSA)
Prep Your Patient

Therapeutic Communication - let your patient have whatever fantasy they want and encourage it! Any fantasy can be a reality with ketamine...seriously.
If they are in so much pain that they are already freaking out and you're not doing your procedure you can give opioids to help calm them down - but remember, ketamine is a powerful analgesia as well...you can always keep them dissociative for a longer duration of time. Situation dependent.
Administer your ketamine dosage diluted in Normal Saline and give it slow...best method to prevent psychiatric disturbance.

Prep Yourself

Place patient on continuous telemonitoring and pulse oximetry

Bonus points: CO2 monitoring


Airway capable Doctor

Watch respirations and breathing closely
May have periods of apnea

Prevent apnea by administering ketamine slowly (approx. 2 minutes diluted or diluted in Normal Saline 50/100mL over a longer period of time)
Expect apnea if you administer ketamine as a fast IV push bolus (1-2 seconds)
Patient may still have apnea - MD must know maneuvers to open airway (head position, jaw thrust, BVM, intubation)




Nasal Cannula on patient - turn on oxygen as needed

I like to have everything connected even if the oxygen is turned off
NRM on standby


Airway Cart, BVM, and Intubation Kit on standby
Suction on standby
Nurse who is dedicated to monitor sedation - lots of paperwork and frequent monitoring including watching those respirations!
Consent

PSA Ketamine Dose

Reuben gives a dissociative dose (Ketamine 1-1.5mg/kg). You can get away with giving an analgesic dose but if a patient comes in with a bad fracture - give the dissociative dose and have propofol on hand to counter ketamine's side effects.
Ketamine can be used as monotherapy for PSA.
Propofol - to counter ketamine's effects (HTN, muscle rigidity, psychiatric emergence, etc.)

Draw up in separate syringe.
Administer in 20/30/40mg IV pushes as needed


Ketofol - Effective but you are not dosing propofol separately.

What is it? Ketamine and propofol drawn up in single syringe and administered at the same time.



Always Treat Psychiatric Disturbance
As your patient metabolizes the ketamine, your patient may "freak out" or have a psychiatric emergence and you must always treat it. It's inhumane to not ignore it and let the patient "ride it out."

Use conventional medications to treat: propofol, midazolam, haloperidol, droperidol (if you can get your hands on it)
Post PSA Ketamine Pearls

NPO until fully alert.
Don't stimulate patient prematurely.
Minimal noise and minimal physical contact.
Nurse with patient entire time monitoring patient until fully alert.

Ketamine for Rapid Sequence Intubation (RSI)

Okay to use for polytrauma or head trauma (ICP) patients.
Has neuroprotective properties - good for ICP/head trauma patients.
Induction agent independent from paralytic - doesn't matter if you use rocuronium or succinylcholine - but we are fans of rocuronium for RSIs in the ED.

Roc Rocks vs. Sux Sucks -LITFL


Extra Ketamine in your syringe?

Can use like a push dose pressor while setting up post intubation drips.