Ketamine as a Prehospital Analgesic: A Systematic Review

Abstract

Objective:Analgesia in the prehospital setting is an extremely important, yet controversial topic. Ketamine, a N-methyl D-aspartate (NMDA) receptor antagonist, has been commonly used in the prehospital setting, including recommendations by the US Department of Defense and by the Royal Australian College of Pain Medicine, despite the paucity of high-level evidence.Methods:Accordingly, a review of the literature was conducted using several electronic medical literature databases from the earliest available records to the time at which the search was conducted (October 2018).Results:The search strategy yielded a total of 707 unique papers, of which 43 were short-listed for full review, and ultimately, ten papers were identified as meeting all the relevant inclusion criteria. The included studies varied significantly in the prehospital context and in the means of administering ketamine. There was only low-grade evidence that ketamine offered a safe and effective analgesia when used as the only analgesic, and only low-grade evidence that it was as effective as alternative opioid options. However, there was moderate evidence that co-administration of ketamine with morphine may improve analgesic efficacy and reduce morphine requirement.Conclusions:Overall, ketamine as a prehospital analgesic may be best used in combination with opioids to reduce opioid requirement. It is suggested that future studies should use a standardized approach to measuring pain reduction. Future studies should also investigate short-term side effects and long-term complications or benefits of prehospital ketamine.

Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis

“…Furthermore, dose differences are not only present inter- but also intra-professionally as demonstrated by a study from a physician-staffed EMS in Germany, which showed differences in pain treatment between surgeons and anaesthesiologists, particularly regarding opioids [ 28 ]. Ketamine has been described as being safe and effective alone – even as effective as an alternative opioid – and also as being able to reduce opioid requirements when used in combination with opioids [ 26 , 29 , 30 ]. After opioids or esketamine administered alone, the by far most commonly administered combination therapy in the presented study was an opioid with esketamine, followed by a combination of an opioid with metamizole.…”

Should Ketamine Not Be Banned? A Scoping Review

“…49 Nonetheless, the consensus is that a sub-anesthetic dose of ketamine has a role to play in the management of pain, especially when used in combination with opioids. 49,52 Additionally, ketamine use has been successful in managing pain crises following sickle cell disease, a commonly seen condition in resource-poor settings due to the poor practice of premarital genetic counseling. 53 Ketamine is a drug to consider for refractory or severe headache, despite the outcome of the THINK trial by Benish et al 54,55 In the study, intranasal ketamine was not superior to intravenous metoclopramide in managing refractory headache.…”

Incidence of Dissociation With Low-Dose Pre-hospital Ketamine in Geriatric Patients With Trauma-Related Pain

“…Regarding the safety of low-dose ketamine, previous studies report a wide range in the incidence of side effects that include, most commonly, vomiting, need for intubation, dissociation or over-sedation, agitation, hallucinations, and emergence reactions [6,8,[10][11][12][13][14][15][16][17][18]. While some studies have reported zero serious adverse events, other studies have reported a moderate number of patients with one or more of the above side effects.…”

“…While some studies have reported zero serious adverse events, other studies have reported a moderate number of patients with one or more of the above side effects. Increasingly, ketamine has been used in the pre-hospital setting [1,3,4,[6][7][8][9][10][11]13,[18][19][20][21]. Indications include rapid sequence intubation by air medical crews, traumatic and nontraumatic pain management, and treatment for behavioral emergencies.…”

“…Increasingly, ketamine has been used in the pre-hospital setting [ 1 , 3 , 4 , 6 - 11 , 13 , 18 - 21 ]. Indications include rapid sequence intubation by air medical crews, traumatic and nontraumatic pain management, and treatment for behavioral emergencies.…”