when administered at sedation/anaesthesia doses, the patient enters a dissociated state which is unlike other sedatives (1)
because ketamine works through an alternative pathway inducing dissociation rather than unconsciousness, the patient remains breathing on their own and able to protect their airway
Ketamine as an analgesic:
has direct action primarily at the NMDA receptors in the central nervous system
has activity at opioid sites and other neurotransmitter pathways (1)
can allow the out‐of‐hospital provider to augment analgesia in a safe and effective manner, reducing opioid requirements while decreasing suffering
in a study (n=251) intravenous ketamine showed non-inferiority for pain reduction compared to morphine (difference in mean pain score change 0.1 [95% CI −0.7 to 0.9]) (2)
a multicenter, single-blind, noninferiority randomized clinical trial comparing ketamine hydrochloride (20 mg, followed by 10 mg every 5 minutes) with morphine sulfate (2 or 3 mg every 5 minutes) in adult patients with out-of-hospital trauma and a verbal pain score equal to or greater than 5
among patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed noninferiority for pain reduction in this randomized clinical trial
observed more adverse events in the ketamine group compared with the morphine group - these adverse events were minor and did not require intervention
a cited concern regarding ketamine use in adults is that of the emergence reaction (1)
sometimes a patient waking up from ketamine dissociation can become agitated, confused and combative
emergence reactions in adults are rapidly managed with benzodiazepines
Reference:
Kitch BB. Out-of-hospital ketamine: review of a growing trend in patient care. J Am Coll Emerg Physicians Open. 2020 Mar 10;1(3):183-189
Le Cornec C et al. Ketamine Compared With Morphine for Out-of-Hospital Analgesia for Patients With Traumatic Pain. JAMA Netw Open 2024 Jan; 7(1): e2352844.
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