Ketamine

Contraindications

Absolute

1. <3 mo old
2. known or suspected schizophrenia (even if currently controlled)

Relative

1. major procedures stipulating posterior pharynx (e.g. endoscopy)
   1. (minor ED orophyarngeal procedures okay)
2. airway instability (e.g. tracheal stenosis)
3. URI or active asthma (unless for induction)
4. CAD, HTN, CHF (? >45 yr old; age cutoff not clearly defined)
5. CNS masses, hdocephalus (head trauma okay)
6. Glaucoma/acute globe (increased IOP)
7. Porphyria/thyroid (theoretical)

Preparation

1. Consent
2. Monitor
3. BVM/O2 mask
4. Suction
5. Ketamine (drawn up)
6. Atropine (ready) [0.01 mg/kg IVP; min 0.1mg, max 0.5mg]
7. Versed (ready) [0.05mg/kg IVP]
8. "Happy Place"

Administration

1. Give initial bolus
   1. Children: 1.5-2 mg/kg SLOW IV* (over 1 min)
   2. Adults: 1 mg/kg SLOW IV* (over 1 min)
   3. Nystagmus = effect
   4. ?maximal dose = 6mg/kg at one time
2. May repeat boluses at 0.5-1 mg/kg increments
3. IV prefered over IM
   1. IM dose 4-5 mg/kg in children (IM discouraged in adults)

O2 ready vs on

1. No data
2. Most don't give atropine prophy (some <5yrs; no evidence)
3. Most don't give versed prophy (evidence against)

Side Effects

1. Transient rash (common)
   1. not harmful
2. Hypersalvation (1.7%)
   1. may give atropine
   2. suction sides only
3. Laryngospasm (<0.4%)
   1. not dose-dependent
   2. assoc with fast IVP
   3. assoc with procedures stimulating gag
4. Transient apnea (<0.3%)
   1. around 2min after IVP
   2. normally BVM needed only
5. Emergence Rx (~2% mod-severe)
   1. give benzo
6. Emesis/persistent ataxia
   1. typically during recovery
   2. no cases of aspiration (airway reflex maintained)
   3. no driving!

Overdose

Prolonged sedation --> full recovery

See Also

Procedural Sedation

Source

Annals of EM. Clinical Practice Guideline for ED Ketamine Dissociative Sedation: 2011 Update