Novel uses of ketamine in the emergency department

ABSTRACT

Introduction

Ketamine is gaining renewed interest among healthcare providers in the emergency department (ED) setting due to its novel clinical applications.

Areas covered

This article provides a comprehensive discussion of ketamine’s pharmacological properties, safety profile, and an overview of current evidence for ketamine in the management of ED patients with acute agitation, pain, depression/suicide ideation.

Expert opinion

Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. Ketamine (0.1–0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain, as well as for chronic painful conditions (cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency). Available literature shows that ketamine (1–2 mg/kg IV or 4–5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.

KEYWORDS:

• Ketamine
• emergency department
• acute pain management
• depression
• psychiatric emergency
• rapid tranquilization

Article highlights

• Ketamine is increasingly used in the emergency department (ED) for the management of acute agitation and pain and has a promising role in acute depressive episodes.

• Ketamine preserves cardiac output, protects laryngeal reflexes, and has high bioavailability making it ideal in patients without IV access or with hemodynamic instability.

• Sub-dissociative dose ketamine (SDK) administered either as an adjunct to opioids or as a single agent is effective and safe for managing a variety of acute and chronic painful conditions in the ED.

• The occurrences of psycho-perceptual adverse effects of SDK are rate dependent and are significantly reduced by using slow and short-term intravenous infusion rather than intravenous push dose.

• Ketamine is a safe, rapid (<5 min), and effective tranquilization agent for ED patients with acute agitation.

• Ketamine (0.5mg/kg IV over 40 min) has been shown to produce antidepressant effects and decrease in suicidal ideation within 4 h of administration, with effects lasting up to 1 week.

This box summarizes key points contained in the article.

Acknowledgments

The authors would like to thank Roy Hatch for his valuable assistance in preparing this manuscript.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer has a share of patents related to the intranasal use of ketamine for depression and suicide. These are licensed to Janssen Pharmaceuticals. They have a share of patents for extending the duration of antidepressant effects of ketamine and reducing its abuse liability licensed to Freedom Biosciences. They have equity in Freedom Biosciences, which has licensed these patents. The remaining reviewers have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.