ketamine Analgesia to RSI Everything In Between how
ketamine Analgesia to RSI & Everything In Between
how does it work? phencyclidine derivative NMDA antagonist μ and κ opioid agonist inhibition of NO synthase desensitization at dorsal horn neurons catecholamine reuptake inhibitor
dissociative anesthesia thalamocortical-limbic system disconnect NMDA antagonist
analgesia Ex. DS myriad uses of ketamine RSI PIASA
courtesy of reuben strayer, MD @emupdates
analgesia
safe trauma procedure pain complex pain syndromes effective back pain ortho injuries rapidly effective refractory/atypical pain
premedication? opiates? benzodiazepines? butyrophenones?
what i like… fentanyl + ketamine except…. . .
opioid failure opioid naïve opioid avoidance opioid seeking
ketamine = morphine (except better? )
Key Concept IBW vs. TBW ideal body weight vs total body weight
0. 1 -0. 25 mg/kg 20 mg over 5 -10 min (20 mg/100 m. L= 600 m. L/hr x 10 min) 20 mg over 60 mins (20 mg/100 m. L= 100 m. L/hr x 60 min) two 100 or 250 m. L bags NS mix, label, drip
oncology failure of long term opioids
palliative care failure of long term opioids
AGITATION
courtesy of reuben strayer, MD @emupdates
Ex. DS Excited Delirium Syndrome
KETAMINE WILL SAVE YOU (and your patient)
profound agitation 4 -5 mg/kg IM (fight for survival)
SPEED and SAFETY
4 -5 mg/kg IM 1 -5 mins
SAFETY intact airway reflexes intact hemodynamics complete dissociation speed
won’t ketamine make it WORSE? tachycardia? hypertension? temperature? metabolic demand?
what about SCHIZOPHRENIA?
what about ALCOHOL?
ketamine for RSI
courtesy of reuben strayer, MD @emupdates
primum non nocere…
hypotension apnea midazolam too light propofol too slow etomidate too fast narrow safe dose range
BUT…
who I wouldn’t give ketamine (mostly) STEMI / NSTEMI dissecting AAA hypertensive crisis
RISK : BENEFIT
TBI / ICH + increased ICP + ketamine SAFE
ketamine increases DECREASES ICP decreases INCREASES CPP
@UCAir. Care. Doc
ketamine RSI 0. 5 -2 mg/kg SLOW IV/IO
hemodynamic stability airway reflexes intact respiratory drive intact profound anesthesia powerful analgesia
hemodynamic stability airway reflexes intact respiratory drive intact profound anesthesia powerful analgesia
RSI is just the BEGINNING
Post Invasive Airway Sedation Analgesia
courtesy of reuben strayer, MD @emupdates
PIASA 0. 5 -4 mg/kg/hr or 0. 5 -2 mg/kg q 5 -30 min
ketamine
ANALGESIA 0. 1 -0. 25 mg/kg slow bolus then infusion
AGITATION 4 -5 mg/kg IM
RSI 0. 5 -2 mg IV/IO
Post Intubation Sedation Analgesia 0. 5 -2 mg/kg q 5 -30 min and / or 0. 5 -2 mg/kg/hour
SAFETY EFFICACY
new frontiers depression antiepileptic bronchodilation
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