Michigan EMS Medication InService Ketamine Course Objectives Identify

Michigan EMS Medication In-Service: Ketamine

Course Objectives • Identify the location of ketamine in the SEM Drug Box, as well as how it may be packaged. • Describe the pharmacokinetics and pharmacodynamics of ketamine. • List the indications and contraindications of ketamine. • Describe how to administer ketamine, as well as list the applicable medication concentration, route and dose(s), per the applicable protocols.

Introduction Purpose – As of June 1, 2018, the following medications were added to the Southeast Michigan Regional Medication Boxes (SEM Drug Box): • • Ketamine Ketorolac (Toradol) Push Dose Epinephrine Ondansetron (Zofran) ODT

Introduction Purpose – This CE will focus on: • Ketamine

Location in the SEM Drug Box One 10 m. L vial containing 1000 mg

Location in the SEM Drug Box Ketamine will NOT be found in the A-Packs

Pharmacokinetics and Pharmacodynamics Class of medication – Ketamine is a N-methyl-D-aspartate (NMDA) receptor antagonist • Type of anesthetic • Common similar examples: – Nitrous oxide and – Phencyclidine (PCP)

Pharmacokinetics and Pharmacodynamics Mechanism of action – Ketamine is a N-Methyl-D-aspartate (NMDA) receptor antagonist – Causes the desirable effect of dissociative amnesia through a combination of analgesia, amnesia, and hypnosis

Pharmacokinetics and Pharmacodynamics Route of administration – Ketamine may be administered IV, IO, IM or IN: Protocol Excited Delirium (Adult Treatment) Pain Management (Procedure) Patient Restraint (Procedure) Patient Sedation (Procedure) Acceptable Route of administration IM IV/IO or IN IM IV/IO, IM or IN

Pharmacokinetics and Pharmacodynamics Onset and duration of action Route Onset Duration IV/IO 30 seconds 10 -15 minutes IM 3 -4 minutes 20 -30 minutes IN 2 minutes 20 -30 minutes Half-life – Approximately 15 minutes

Pharmacokinetics and Pharmacodynamics Side effects – Increased BP and heart rate (moderate) – Emergence reactions • Hallucinations, nightmares or vivid dreams • Rare • More common with larger doses of ketamine

Indications Ketamine SHOULD be administered in the following situations: – Pain management – Excited delirium • If midazolam has not achieved the desired effect after 5 minutes – Patient restraint • If midazolam has not achieved the desired effect after 5 minutes – Patient sedation

Contraindications Ketamine should NOT be administered in the following situations: – Patients allergic or hypersensitive to ketamine

Applicable protocols • Pain Management (procedures section) – Indicated for patients with “significant” pain • >4 on pain scale • Adults and pediatrics

Applicable protocols • Pain Management (procedures section) – Remember, >8 can still receive opioid analgesia • Do not need to contact medical control in this situation

Applicable protocols • Pain Management (procedures section) – Contact medical control if: • Ketamine was administered first, but the patient is still in pain and you’d like to now give an opioid analgesic

Applicable protocols • Excited Delirium (adult treatment section)

Applicable protocols • Excited Delirium (adult treatment section) – Administer midazolam first

Applicable protocols • Excited Delirium (adult treatment section) – Administer midazolam first – Administer ketamine if patient remains combative after 5 minutes

Applicable protocols • Patient Restraint (procedure section)

Applicable protocols • Patient Restraint (procedure section)

Applicable protocols • Patient Restraint (procedure section) – Ketamine is indicated as a chemical restraint secondary to midazolam

Applicable protocols • Patient Sedation (procedure section)

Applicable protocols • Patient Sedation (procedure section)

Applicable protocols • Patient Sedation (procedure section)

How to administer ketamine 1. Remove ketamine from the SEM Drug Box

How to administer ketamine 2. Verify the correct medication and concentration – Medication: Ketamine – Concentration: 1000 mg/10 m. L – Dose: Protocol dependent

How to administer ketamine 3. Draw the medication from the vial – Dose is protocol and route dependent – Ketamine may be administered IV, IO, IM or IN IV IO IM IN

How to administer ketamine 4. Administer the medication, per protocol – IV/IO • Administer slowly • Dilute ketamine with equal parts normal saline prior to injection IV IO

How to administer ketamine 4. Administer the medication, per protocol – IV/IO Protocol Pain Management IV/IO dose Adult (or > 80 lbs. ): 0. 2 mg/kg • Maximum single dose 25 mg • May repeat after 10 minutes to a maximum dose of 50 mg

How to administer ketamine 4. Administer the medication, per protocol – IV/IO Protocol Pain Management IV/IO dose Pediatric (or < 80 lbs. ): 0. 2 mg/kg • Maximum single dose 25 mg • May repeat after 10 minutes to a maximum dose of 0. 4 mg/kg

How to administer ketamine 4. Administer the medication, per protocol – IV/IO Protocol Patient Sedation IV/IO dose Adult: 1 -2 mg/kg titrated slowly • MUST contact medical control for repeat doses or additional sedation

How to administer ketamine 4. Administer the medication, per protocol – IV/IO Protocol Patient Sedation IV/IO dose Pediatric: 1 -2 mg/kg titrated slowly • MUST contact medical control for repeat doses or additional sedation

How to administer ketamine 4. Administer the medication, per protocol – IM • Expose and locate the injection site, if possible and clean the injection site with an alcohol prep – NOTE: Exposing the injection site may be difficult during an encounter with a patient that requires chemical restraint – In extreme situations, IM injection of ketamine may be performed through clothing, if necessary to support patient and provider safety. Thorough documentation in the patient care record (PCR) should support this method if utilized. ) IM

How to administer ketamine 4. Administer the medication, per protocol – IM Protocol Excited Delirium And Patient Restraint IM dose Adult: 4 mg/kg • Administer midazolam FIRST • After 5 minutes if the patient remains combative administer ketamine • NOT APPROVED FOR PEDIATRICS

How to administer ketamine 4. Administer the medication, per protocol – IM Protocol Patient Sedation IM dose Adult: 4 mg/kg Pediatric: 4 mg/kg MUST contact medical control for repeat doses or additional sedation

How to administer ketamine 4. Administer the medication, per protocol – IN • Rapidly administer one half of the dose of medication, briskly pushing plunger. • Repeat with other nostril delivering the remaining volume of medication • Note: Maximal dose per nostril is 1 cc IN

How to administer ketamine 4. Administer the medication, per protocol – IN Protocol Pain Management IN dose Adult (or > 80 lbs. ): 0. 5 mg/kg • Maximum single dose 25 mg • May repeat after 10 minutes to a maximum dose of 50 mg

How to administer ketamine 4. Administer the medication, per protocol – IN Protocol Pain Management IN dose Pediatric (or < 80 lbs. ): 0. 5 mg/kg • Maximum single dose 25 mg • May repeat after 10 minutes to a maximum dose of 0. 4 mg/kg

How to administer ketamine 4. Administer the medication, per protocol – IN Protocol Patient Sedation IN dose Adult: 1 -2 mg/kg Pediatric: 1 -2 mg/kg MUST contact medical control for repeat doses or additional sedation

Medication Section 9 • Every medication available in the SEM Drug Box and A-Pack is now detailed in “Section 9 Medications” of the State of Michigan EMS Protocols – Click here to access the digital version of Section 9

Medication Section 9 • Ketamine 9 -29 – – Applicable Protocols Indications Contraindications Dosing: • Adult • Pediatrics – Expected Effects – Side Effects

Michigan EMS Medication In-Service: Ketamine Questions? ? ?