September 5, 2019

Background: Working in the emergency department means frequently performing painful procedures on patients, often we turn to procedural sedation to make these procedures more tolerable for patients, families and clinicians alike.  Ketamine is often used for this purpose, particularly in pediatrics, however, many clinicians are reluctant to use this agent due to concerns for recovery agitation or the dreaded “emergence phenomenon.” Clinicians often turn to the co-administration of various agents, including benzodiazepines and antipsychotics, to blunt this effect.  The definition of recovery agitation and the means by which it is measured are inconsistent in the previous literature, leading to a dearth of evidence as to whether the practice of co-administration of medications is effective in reducing recovery agitation.

July 1, 2019

EMS rolls in with a 28 year-old male brought in for severe agitation after being found smashing glass bottles in the street. As police approached him, he cut himself with the broken glass and was bleeding significantly, though they could not fully evaluate his wounds due to his agitation. He was restrained by 6 officers and brought to you without IV access. He is thrashing around on the gurney in 4-point restraints, with blood soaking through the gauze bandages on his arms. What do you do?

July 3, 2018

Background: In recent years, ketamine use has dramatically increased in the Emergency Department (ED). There are four major indications for the use of ketamine in the ED: analgesia with low dose ketamine (LDK), induction for rapid sequence intubation, procedural sedation and sedation of the agitated patient. A number of relative contraindications for ketamine exist though many of them have been debunked through analysis of the evidence. This includes the dogma that ketamine cannot be used in patients with head trauma (for fear of increasing the ICP) or in patients with hypertension or tachycardia.

One contraindication that persists, though, is that of a history of psychiatric illness. Ketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist and it can produce a broad range of cognitive and behavioral disturbances including psychosis. These disturbances are short-lived in the majority of individuals but there is a fear that ketamine can cause decompensation of psychiatric illness. The ACEP Clinical Policy lists psychiatric illness as an absolute contraindication for dissociative sedation with ketamine (Green 2011).

March 16, 2017

Background: Etomidate and ketamine are both routinely used as induction agents during rapid sequence intubation (RSI) in trauma patients. It is well established that etomidate transiently suppresses the adrenal gland through inhibition of the 11-beta hydroxylase enzyme. Though adrenal suppression in theory can cause deleterious outcomes, there is no high-quality evidence demonstrating a change in patient centered outcomes with it’s use in comparison to alternate agents. Ketamine has long been an alternative induction agent to etomidate but historical concerns, though disproven in more recent literature, limited it’s use due to concerns over increasing intracranial pressure.

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