Ketamine Non-opioid; analgesic and dissociative properties Dissociation is not dose-responsive above 1mg/kg, it is either present or absent - additional doses do not enhance or

deepen sedation Induces the analgesic and dissociative state within 60 seconds after a single IV dose and within 3 to 5 minutes for an IM

dose. This sedation lasts approximately 10 to 15 minutes for IV doses and 20 to 30 minutes for IM doses. Exerts sympathomimetic effects producing mild increases in blood pressure, heart rate, cardiac output, and myocardial

oxygen consumption Shown to alleviate bronchospastic activity and reduce airway resistance in patients with pulmonary disease May have a direct neuroprotective role

Review articles

Bredmose et al (2009) EMJ – Pre-hospital use of ketamine for analgesia and procedural sedation [PMID: 19104109]

Retrospective trauma review 1220 patients received ketamine over a 5 year period IV ketamine the preferred analgesia on scene by London HEMS doctors No cases where airway manoeuvres were required post administration; no significant complications Not all side effects documented

Jennings et al (2012) Annals of Emerg Med – Morphine and Ketamine is superior to Morphine alone for Out-of-Hospital Trauma Analgesia: A randomized Controlled Trial [PMID: 22243959]

Prospective, randomized, controlled, open-label study (unblinded due to safety reasons) 136 patients enrolled, randomly assigned to morphine & ketamine or morphine alone Ketamine & morphine group had larger decrease in pain score on arrival at ED; quicker reduction of pain Ketamine group had larger incidence of mild adverse effects, mainly emergence phenomenon, disorientation, altered LOC,

sympathetic changes (hypertension, tachycardia etc.) Methoxyflurane given to most patients prior to IV analgesia intervention No clinically significant differences in vital signs after enrolment

Tran et al (2014) A Comparison of Ketamine and Morphine Analgesia in Prehospital Trauma Care: A Cluster Randomized Clinical Trial in Rural Quang Tri Province, Vietnam [PMID: 24400915]

Prospective, cluster-randomized design (unblinded) 169 trauma patients were treated outside hospital settings with ketamine, while 139 patients were treated with morphine. Patient experience of pain not documented Five patients in the ketamine group and 10 patients in the morphine group experienced negative treatment effects, defined

as more pain on admission than before analgesic treatment Nausea and vomiting were observed in 27 patients (19%) in the morphine group and 8 patients in the ketamine group (5%) Three patients in the ketamine group had excessive salivation, and 19 patients (11%) demonstrated agitation.

Svenson et al (2007) AJEM - Ketamine for prehospital use: new look at an old drug [PMID: 17920984] Retrospective study of all patients transported by a regional aeromedical program 40 patients received ketamine over 3 years All had already received large doses of narcotics without relief Most patients only required 1 dose of ketamine to achieve adequate pain relief No patients in any subset (burns, trauma, cardiac) suffered hypotension post administration of ketamine