Hot off the press: Clinical practice guideline for ketamine in the ED

3:00 AM in article review, education, hot off the press, pediatrics

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.

Hhhmmmm...how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.

This practice guideline was updated from a previous 2004 version because of new research that proved/disproved the way ketamine was being utilized. It was compiled by four physicians that are experts in the field of ketamine sedation, two of which wrote the 2004 practice guideline. Updated research was found by performing a MEDLINE search from January 2003 to November 2010 using the search term "ketamine".

Highlights:

1. Adults have been included in the 2011 guidelines.

2. Adjunctive medications

• Prophylactic ondansetron can help reduce vomiting. The number needed to benefit = 9.
• No need to co-administer atropine or glycopyrrolate for oral secretions.
• Prophylactic midazolam 0.3 mg/kg may prevent recovery reactions in adults (but not children). The number needed benefit = 6.

3. Contraindications

• Age < 3 months because of risk of airway complications
• Known or suspected schizophrenia (even if currently stable)
• Head trauma has been removed as a contraindication.

4. Route of administration

• IV administration appears to be preferred over IM, because of faster recover and fewer episodes of emesis.
• IV route: Peak concentration and onset = 1 min, duration of dissociation = 5-10 min, time from dose-to-discharge = 50-110 min
• IM route: Peak concentration and onset = 5 min, duration of dissociation = 20-30 min, time from dose-to-discharge = 60-140 min 

5. Complications

• Laryngospasm has been reported to be around 0.3%. What do you do when this happens? You'll just have to read this previous post to find out.

Reference

Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine. 2011 - in press. PMID: 21256625
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