Current Concepts in Ketamine Therapy in the Emergency Department (Pharmacology CME and Pain Management CME)

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Delivery Method:	Online
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Publication Date: May 2024 (Volume 26, Number 5)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 05/01/2027.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits and 1 Pain Management CME credit, subject to your state and institutional approval.

Author

Peer Reviewers

Abstract

Ketamine has been in use since its development as a dissociative anesthetic in the 1960s, but it was largely confined to the operating theater or austere environments until used by emergency physicians to facilitate painful procedures in children. As the unique effects of ketamine across its dose-response curve were understood, new applications emerged. In low doses, ketamine has found an important role alongside or instead of opioids in the management of severe pain, and methods to slow its absorption allow higher, more effective doses while attenuating psychoperceptual effects. Ketamine’s unique anesthetic properties have inspired its use as an induction agent for intubation without a paralytic and for the rapid, safe control of dangerously agitated patients. Emerging uses for ketamine in acute care include treatment for status epilepticus and alcohol withdrawal syndrome; however, its most important rising indication may be as an emergency treatment of depression and suicidality.

Case Presentations

A 43-year-old man presents to the ED after a trip and fall onto his outstretched hand…

• The patient’s examination is notable for a dinner-fork deformity, and wrist radiograph shows a distal radius fracture with dorsal angulation.
• In order to reduce the fracture, procedural sedation with ketamine is performed. Though the usual dissociative dose of ketamine is ≥1 mg/kg IV, because you anticipated the procedure to be very brief, you chose a smaller dose of 40 mg.
• Shortly after administration, the patient begins screaming in terror and is obviously anguished by hallucinations and feelings of unreality. The clinical team is very concerned and looks to you for next steps…

A 22-year-old man presents after being thrown from his motorcycle; he was not wearing a helmet and has head injuries…

• Your primary survey demonstrates a low Glasgow Coma Scale score, failure to protect the airway, blood pressure of 77/40 mm Hg, and laxity on manual pelvic compression.
• Portable chest x-ray is unremarkable, but pelvic radiograph demonstrates an open-book pelvic fracture.
• You decide to intubate the patient for airway protection and presumptive need for operative management. Given the patient’s hypotension, you call for 100 mg of rocuronium and 75 mg ketamine for rapid sequence intubation. Your colleague voices concern that ketamine is contraindicated in brain-injured patients…

A 74-year-old woman presents with hematemesis…

• The patient has a history of metastatic pancreatic cancer and has palliative goals of care; she does not wish to have any life-extending procedures done.
• She is in severe cancer-related pain, but is on high doses of opioids at home and describes a recent ED presentation in which staff was unable to control her pain with usual doses of opioids.
• The patient and her husband request that no tests or treatments be done beyond making her comfortable. She knows she has reached the end of her life and asks whether there is anything you can give her besides opioids to take away her pain…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.