Kris dives into the evil of Ketamine that we FOAM’ers seem to forget about. Ketamine may be the wonder drug, but it has a grave limitation that can’t be overlooked.

4. Special K
Friend?
CBCEMP Mini-Con
January 2018

5. or Foe?

6. The setup:
• 25 y/o severely traumatized man
• BP 84/60, HR 120, RR 26, GCS 7
• Transport underway
• Blood transfusion ongoing
• Needs an airway

7. The play:
• Continuing resuscitation
• Plan to intubate with:
• Ketamine and whatever
• Going through the excited EM
resident, flight RN, or paramedic’s
mind, “Ketamine is perfect for this!”

8. The surprise:
• Patient becomes more and more
hypotensive despite blood
transfusion and push-dose epi.
• Codes one minute after induction and
is unable to be resuscitated.
• “Couldn’t be the ketamine!”
• “Ketamine raises the blood pressure!”
• “It’s safe for patients like this!”

10. History:
• 1962 – Wayne State / Parke-Davis
• 1964 – First human experimental use
• Late 1960’s – Vietnam surgery
• 1970 – FDA approval
• 1980’s – Abuse increased
• 1999 – Non-narcotic Class III CS

11. Pharmacology:

12. Pharmacology:
• NMDA receptor antagonist
• α-1 and β-2 agonist
• Anticholinergic (Muscarinic Ach)
• Reuptake inhibitor:
• Norepi, Dopamine, GABA, Serotonin
• Decreases NO production
• Adrenocortical stimulation
• Anti-inflammatory actions
• Weak μ- and κ-opioid agonist

13. Clinically:
• Anesthetic
• Analgesic
• Amnesic
• Dissociative sedative-
hypnotic
• Bronchodilator
• Anti-epileptic??
• Neuroprotectant??
• Anti-depressant??

14. Perfect for:
• The difficult airway
• The hypoxic patient who needs RSI
• The opiate-tolerant patient who hurts
• The opiate-abusing patient who hurts
• The crazy, crazy-strong patient
• The severe asthmatic
• The patient who keeps shaking
• And likely others!

15. Possible Side Effects:
• Nausea/Vomiting (10-25%)
• Agitation/Emergence Rxn (5-20%)
• Clonus (7%)
• Salivation
• Apnea

16. 0.1-0.2
mg/kg
0.3-0.7
mg/kg
0.8-2+
mg/kg
Analgesia
Recreational
Partial Dissociation
Full Dissociation
Ketamine Dose Continuum

20. Cardiovascular effects:
• Direct myocardial depression
• Usually increases cardiac output
• Central sympathomimetic effects
• B1 activation
• Norepi/Dopamine RI
• Ach antagonist
• Increased vascular tone
• A1 activation
• Norepi/Dopamine RI

22. Group
HypoTN
%
HTN
%
HR
incr.
bpm
Low SI 2 40 20
High SI 26 13 9
Shock Index = HR/SBP

23. Low SI
(<0.9)
High SI
(>0.9)

25. Why we should be friends:
• Safety record
• Best tool for a variety of things
• Versatility as a multitasker

27. But, be weary:
• Nausea/Vomiting
• Agitation/Emergence Rxn
• Doesn’t always improve BP
• May elicit cardiovascular collapse

28. Questions?
Kris Thompson
ThompsonKris@health.missouri.edu