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