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
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.
- 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.
- 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
