Ketamine

Contraindications

Absolute

1. <3 mo old
2. Known or suspected schizophrenia, even if currently stable or controlled w/ meds

Relative

1. Major procedures involving posterior pharynx (e.g. endoscopy)
   1. Typical minor ED oropharyngeal procedures are okay
2. Airway instability (e.g. tracheal stenosis, tracheal surgery)
3. Active pulmonary infection, including URI or asthma (unless for induction)
4. CAD, HTN, CHF
5. CNS masses, hydrocephalus (head trauma okay)
6. Glaucoma/acute globe injury
7. Thyroid disorder or on thyroid medication

Preparation

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

Administration

1. Give initial bolus
   1. Children: 1.5-2 mg/kg IV (over 30-60sec)
   2. Adults: 1 mg/kg IV (over 30-60sec)
   3. Nystagmus = effect
2. May repeat boluses at 0.5-1 mg/kg increments
3. IV prefered over IM (faster recovery, less emesis)
   1. IM dose 4-5 mg/kg in children
      1. Repeat dose if sedation is inadequate after 5-10min or if additional doses required

Side Effects

• Airway misalignment requiring repositioning of head (occasional)
• Laryngospasm (0.3%)
  • Only associated with unusually high IV doses
  • Tx = BVM ventilation; intubation is rarely needed
• Apnea or respiratory depression (0.8%)
  • Associated with rapid IV push
  • Transient
• Hypersalivation (rare)
• Emesis, usually well into recovery (8.4%)
• Recovery agitation (mild in 6.3%, clinically important in 1.4%)
• Muscular hypertonicity and random, purposeless movements (common)
• Clonus, hiccupping, or short-lived nonallergic rash of face and neck

Discharge Criteria

1. Return to pretreatment level of verbalization/awareness
2. Return to pretreatment level of purposeful neuromuscular activity
3. Do NOT have to wait until the pt can ambulate or tolerate PO

See Also

Procedural Sedation

Source

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