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How to use ketamine fearlessly for all its indications smacc 2015 no builds

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SMACC Conference Reuben Strayer Ketamine is best known for producing dissociative anesthesia by a unique mechanism where cardio-respiratory function is preserved. It has an extraordinary safety profile that lends itself well to a variety of uses in the emergency department, intensive care, and pre-hospital environments. We will discuss many of these applications, with a focus on the myths and controversies that might discourage emergency clinicians from taking advantage of this remarkable agent.

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How to use ketamine fearlessly for all its indications smacc 2015 no builds

  1. 1. Ketamine: How to Use it Fearlessly For All its Indications reuben j. strayer @emupdates
  2. 2. Ketamine: How to Use it Fearlessly For All its Indications reuben j. strayer @emupdates no disclosures / conflicts
  3. 3. the effects of ketamine on the body hypertension tachycardia bronchodilation
  4. 4. the effects of ketamine on the brain
  5. 5. the effects of ketamine on the brain
  6. 6. ketamine brain continuum analgesia recreational partially dissociated dissociated 10 mg 30 mg 50 mg 100 mg
  7. 7. pro complete analgesia, sedation, amnesia airway reflexes maintained cardiorespiratory tone augmented rapid onset, predictable duration can be used intramuscularly unmatched margin of safety con hypertension, tachycardia hypertonicity hypersalivation no reversal agent psychiatric distress ketamine for procedural sedation Brown 2008 Chong 2013
  8. 8. ketamine for procedural sedation anticipate ketamine brain continuum - be careful with small doses treat prevent pre-induction comfort pre-induction coaching psychiatric distress is not a reason not to use ketamine vs. ketofol Green 2011
  9. 9. ketamine for RSI partial dissociation and emergence distress not a concern vs etomidate can be used in all patients where increase in HR and BP is acceptable take advantage of the flat part of the brain continuum: dose big unless obtunded and very hypotensive the contraindication myths have been debunked increased ICP increased IOP psychiatric disease Chang 2013 Filanovsky 2010 Himmelseher 2005 Sehdev 2006 Halstead 2012 Drayna 2011 Le Cong 2010 excellent for all hypotensive patients, including trauma optimal for patients being intubated for asthma or COPD
  10. 10. ketamine for post-intubation sedation push ketamine, not vecuronium
  11. 11. severe oxygenation or ventilation deficit? NIV, KSIyes no yes preoxygenate obtunded, no blood pressure? NoSIyes resuscitate time, cooperation? no KSI double setup yes awake intubation high risk to vomit? yes RSI double setup no yes glycopyrrolate lidocaine head elevation NG tube LMA ventilation if needed high concern for difficult laryngoscopy? RSIno no ready with plan B, C, D apneic? yes RSI tolerates optimal preoxygenation? DSInono
  12. 12. abdominal migraine chronic ischemic pain atypical odontalgia phantom pain postherpetic neuralgia post-stroke pain spinal injury pain TMJ joint arthralgia intractable headache ketamine for analgesia ketamine is a powerful analgesic - 0.15 mg/kg when opioids are not effective when opioids are not desired daily opioid users with chronic pain and some other reason to be in the ED Bell 2009 Ahern 2013 Fine 1999 Gharaei 2012 Jennings 2011 Richards 2012 Zempsky 2010 Beaudoin 2014 Ding 2014 low back pain chronic pancreatitis fibromyalgia myofascial pain syndrome complex regional pain syndrome sickle cell opioid withdrawal neuropathic pain cyclic vomiting gastroparesis
  13. 13. ketamine for analgesia ketamine is a powerful analgesic - 0.15 mg/kg when opioids are not effective when opioids are not desired daily opioid users with chronic pain and some other reason to be in the ED recovered opioid addicts with acute pain marginal blood pressure or breathing bolus vs. drip Bell 2009 Ahern 2013 Fine 1999 Gharaei 2012 Jennings 2011 Richards 2012 Zempsky 2010 Beaudoin 2014 Ding 2014 20 mg over 10 minutes, then 20 mg/hour titrated to effect not PSA - no monitoring required
  14. 14. ketamine for asthma Denmark 2006 Goyal 2013 Heshmati 2003 Shlamovitz 2011
  15. 15. ketamine for tranquilization speed, safety, reliability, IM increases in HR and BP less than uncontrolled thrashing rage this is procedural sedation - treat as such ketamine 500 mg IM x 1 ACEP 2009 Roberts 2001 Burnett 2012
  16. 16. ketamine brain continuum analgesia recreational partially dissociated dissociated 10 mg 200 mg ?
  17. 17. ketamine for suicidality?
  18. 18. use ketamine fearlessly procedural sedation airway management analgesia asthma tranquilization emupdates.com

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