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Ketamine: Just for the OR??.....Nope!

Ketamine was first synthesized six decades ago as a PCP derivative, but the medication has just recently become a hot button topic in EMS. Some media stories in Colorado have fueled this and propelled it into the national spotlight. Of late, it has come under some heavy scrutiny. However, is the bad reputation warranted, or is it simply a story with a great headline?? That is certainly still up for debate.

Few likely remember that Ketamine was given on the battlefield in Vietnam in its early days, while others many recall it as a “club drug” in the 80’s. It was first approved as an anesthetic, but in reality, as more research is completed – it has been found to have many applications across varying fields of medicine. It’s a pharmacological Swiss army knife.

Ketamine works on many brain targets and that helps speak to its “many lives” and versatility. At high doses (> 1 mg/kg), it can be a great anesthetic, at really low doses (0.1-0.3 mg/kg), it appears to have analgesic effects on patients. Ketamine as a pain management drug can be preferred when opioids are non-effective or you’re trying to avoid opioids altogether due to the patient’s history. Today, nasal formulations have come out to treat depression, but other early research suggests it may be able to help with seizure disorders, excited delirium, agitation, and PTSD amongst other things. Regarding psychological illness, data is beginning to indicate it can treat what was historically described as treatment resistant depression, not in 4-6 weeks, but in just a few hours. As an anti-depressant it seems as if the patient feels distinctly better with Ketamine when compared to more traditional oral medications, where the positive differences could be viewed as subtle at best, thus taking more time to establish patient confidence. In addition to its effects on depression, it may also have an independent benefit/effect on suicidal ideation as well.

This so-called miracle drug is not benign though, and like any other medication, it has side effects and significant risks if not used appropriately. Of particular importance to EMS and other healthcare providers is the dreaded K-Hole. As the dose of Ketamine increases (in between the analgesic and anesthetic dose spectrum), its effects on the human body can change and be quite profound. At some point you will begin to dissociate from both yourself and reality, in what some describe as an out of body experience. This leaves you temporarily unable to interact with others or the world around you. However, it's important to mention that before you get to this space of dissociation, you can experience this “emergence phenomena” where you can become agitated and maybe even combative…a scary time for the patient and clinician alike. Consider small doses of Versed (if your protocol or online medical direction allows) to help fend off or even prevent this emergence reaction.

In summation, remember Ketamine is generally considered safe, it allows you to maintain your airways reflexes (laryngospasms are rare), it may actually be neuroprotective in cases of head trauma/increased ICP. It has many applications and the evidence surrounding its use is GOOD! – just use when appropriate and be sure the dosage is warranted given the patient presentation. Alignment with your desired overall clinical goals and outcomes are paramount.

February 6, 2023

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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