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Fuller RG, Kikla EM, Fawcett APW, Hesling JD, Keenan S, Flarity KM, Patzkowski MS, April MD, Bebarta VS, Schauer SG. Low-dose ketamine for acute pain: A narrative review. Am J Emerg Med 2024; 86:41-55. [PMID: 39326173 DOI: 10.1016/j.ajem.2024.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/30/2024] [Accepted: 09/11/2024] [Indexed: 09/28/2024] Open
Abstract
INTRODUCTION Acute pain management is a critical component of prehospital and emergency medical care. Opioids are effective; however, the risks and side-effects of opioids have led providers to use low-dose ketamine (LDK) for safe and effective treatment of acute pain. METHODS We conducted a scoping narrative review to explore the efficacy of LDK for the treatment of acute pain in the prehospital setting and emergency department (ED) setting. The prehospital review includes studies evaluating the use of LDK in both civilian and military settings. We utilized PubMed to identify prospective and retrospective clinical studies related to this topic. We limited study inclusion to quality prospective and retrospective clinical and observational studies published in the English language prior to January 30, 2024. We did not limit study inclusion based on patient population or mode of administration. We utilized the PRISMA-ScR checklist to conduct this review. RESULTS Using our methodology, we found 249 publications responsive to our search strategy. Of these, 178 publications were clearly outside inclusion criteria based on abstract review. Seventy-one studies were sought for retrieval and more detailed review. Of these, 22 records were excluded after review and 43 met initial inclusion criteria. An additional 22 studies were found via snowballing. In total, 64 studies met inclusion criteria for this analysis. 21 studies related to the treatment of acute pain in the prehospital setting, four of which were randomized clinical trials (RCTs). Forty-three studies evaluate the treatment of acute pain in the ED. This included 28 RCTs. Taken together, the studies suggest that LDK is non-inferior to opioids when used alone. When used as an adjunct to opioid therapy, LDK can provide an opioid-sparing effect. Ketamine doses <0.5 mg/kg were not associated with significant side effects. CONCLUSIONS LDK is a safe and effective option for acute pain treatment. It can be used as an alternative therapy to opioids or used in conjunction with them to reduce opioid exposure through its opioid-sparing effect. Importantly, LDK is available in a variety of formulations including intramuscular, intravenous, and intranasal, making it an effective acute pain treatment option in both the prehospital and ED settings. LDK holds promise as an emergency treatment in the evolving landscape of acute pain management.
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Affiliation(s)
- Robert G Fuller
- University of Colorado School of Medicine, Aurora, Colorado, USA; Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Evan M Kikla
- University of Colorado School of Medicine, Aurora, Colorado, USA; Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrew P W Fawcett
- Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA; University of Colorado School of Dental Medicine, Aurora, Colorado, USA
| | - John D Hesling
- Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Physical Medicine & Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sean Keenan
- Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Joint Trauma System, Defense Health Agency, San Antonio, TX, USA
| | - Kathleen M Flarity
- University of Colorado School of Medicine, Aurora, Colorado, USA; Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael D April
- 40th Forward Resuscitative Surgical Detachment, Fort Carson, CO, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Vikhyat S Bebarta
- University of Colorado School of Medicine, Aurora, Colorado, USA; Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA; 59th Medical Wing, JBSA Lackland, TX, USA
| | - Steven G Schauer
- University of Colorado School of Medicine, Aurora, Colorado, USA; Center for COMBAT Research, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Boese M, Berman RY, Qiu J, Spencer HF, Radford KD, Choi KH. Effects of Mild Closed-Head Injury and Subanesthetic Ketamine Infusion on Microglia, Axonal Injury, and Synaptic Density in Sprague-Dawley Rats. Int J Mol Sci 2024; 25:4287. [PMID: 38673871 PMCID: PMC11050690 DOI: 10.3390/ijms25084287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Mild traumatic brain injury (mTBI) affects millions of people in the U.S. Approximately 20-30% of those individuals develop adverse symptoms lasting at least 3 months. In a rat mTBI study, the closed-head impact model of engineered rotational acceleration (CHIMERA) produced significant axonal injury in the optic tract (OT), indicating white-matter damage. Because retinal ganglion cells project to the lateral geniculate nucleus (LGN) in the thalamus through the OT, we hypothesized that synaptic density may be reduced in the LGN of rats following CHIMERA injury. A modified SEQUIN (synaptic evaluation and quantification by imaging nanostructure) method, combined with immunofluorescent double-labeling of pre-synaptic (synapsin) and post-synaptic (PSD-95) markers, was used to quantify synaptic density in the LGN. Microglial activation at the CHIMERA injury site was determined using Iba-1 immunohistochemistry. Additionally, the effects of ketamine, a potential neuroprotective drug, were evaluated in CHIMERA-induced mTBI. A single-session repetitive (ssr-) CHIMERA (3 impacts, 1.5 joule/impact) produced mild effects on microglial activation at the injury site, which was significantly enhanced by post-injury intravenous ketamine (10 mg/kg) infusion. However, ssr-CHIMERA did not alter synaptic density in the LGN, although ketamine produced a trend of reduction in synaptic density at post-injury day 4. Further research is necessary to characterize the effects of ssr-CHIMERA and subanesthetic doses of intravenous ketamine on different brain regions and multiple time points post-injury. The current study demonstrates the utility of the ssr-CHIMERA as a rodent model of mTBI, which researchers can use to identify biological mechanisms of mTBI and to develop improved treatment strategies for individuals suffering from head trauma.
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Affiliation(s)
- Martin Boese
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD 20814, USA; (M.B.); (K.D.R.)
| | - Rina Y. Berman
- Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, MD 20814, USA;
| | - Jennifer Qiu
- Department of Chemistry and Biochemistry, University of Maryland, College Park, MD 20742, USA;
| | - Haley F. Spencer
- Program in Neuroscience, Uniformed Services University, Bethesda, MD 20814, USA;
| | - Kennett D. Radford
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD 20814, USA; (M.B.); (K.D.R.)
| | - Kwang H. Choi
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD 20814, USA; (M.B.); (K.D.R.)
- Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, MD 20814, USA;
- Program in Neuroscience, Uniformed Services University, Bethesda, MD 20814, USA;
- Department of Psychiatry, F. E. Hébert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
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Hudson IL, Staudt AM, Burgess M, Hinojosa-Laborde C, Schauer SG, Newberry RK, Ryan KL, VanFosson CA. Patterns of Palliation: A Review of Casualties That Received Pain Management Before Reaching Role 2 in Afghanistan. Mil Med 2023; 188:108-116. [PMID: 36099060 DOI: 10.1093/milmed/usac211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/09/2022] [Accepted: 07/01/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Battlefield pain management changed markedly during the first 20 years of the Global War on Terror. Morphine, long the mainstay of combat analgesia, diminished in favor of fentanyl and ketamine for military pain control, but the options are not hemodynamically or psychologically equivalent. Understanding patterns of prehospital analgesia may reveal further opportunities for combat casualty care improvement. MATERIALS AND METHODS Using Department of Defense Trauma Registry data for the Afghanistan conflict from 2005 to 2018, we examined 2,402 records of prehospital analgesia administration to assess temporal trends in medication choice and proportions receiving analgesia, including subanalysis of a cohort screened for an indication with minimal contraindication for analgesia. We further employed frequency matching to explore the presence of disparities in analgesia by casualty affiliation. RESULTS Proportions of documented analgesia increased throughout the study period, from 0% in 2005 to 70.6% in 2018. Afghan casualties had the highest proportion of documented analgesia (53.0%), versus U.S. military (31.9%), civilian/other (23.3%), and non-U.S. military (19.3%). Fentanyl surpassed morphine in the frequency of administration in 2012. The median age of those receiving ketamine was higher (30 years) than those receiving fentanyl (26 years) or nonsteroidal anti-inflammatory drugs (23 years). Among the frequency-matched subanalysis, the odds ratio for ketamine administration with Afghan casualties was 1.84 (95% CI, 1.30-2.61). CONCLUSIONS We observed heterogeneity of prehospital patient care across patient affiliation groups, suggesting possible opportunities for improvement toward an overall best practice system. General increase in documented prehospital pain management likely reflects efforts toward complete documentation, as well as improved options for analgesia. Current combat casualty care documentation does not include any standardized pain scale.
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Affiliation(s)
- Ian L Hudson
- Brooke Army Medical Center, San Antonio, TX 78234, USA.,US Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | | | - Matthew Burgess
- US Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | | | - Steven G Schauer
- Brooke Army Medical Center, San Antonio, TX 78234, USA.,US Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | - Ryan K Newberry
- Brooke Army Medical Center, San Antonio, TX 78234, USA.,US Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | - Kathy L Ryan
- US Army Institute of Surgical Research, San Antonio, TX 78234, USA
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Randall MM, Raae-Nielsen J, Choi M, Dukes WS, Nesper T, Mesisca MK. Incidence of Dissociation With Low-Dose Pre-hospital Ketamine in Geriatric Patients With Trauma-Related Pain. Cureus 2022; 14:e27698. [PMID: 36081959 PMCID: PMC9440993 DOI: 10.7759/cureus.27698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Sub-dissociative ketamine has been used increasingly for the treatment of acute pain in a wide variety of settings. While there are studies evaluating its use in the geriatric population, no studies have described its safety in the pre-hospital geriatric trauma patient. The objective of this study was to define the incidence of dissociation with low-dose pre-hospital ketamine in geriatric trauma patients. Methods Using our county emergency medical services database, we identified all trauma patients greater or equal to 65 years of age who received pre-hospital ketamine for pain after the implementation of a low-dose ketamine protocol. We retrospectively reviewed pre-hospital and emergency department records for demographics, traumatic injuries, Glasgow Coma Score, emergency department length of stay and disposition, and hospital length of stay. This group was compared to a similar population of trauma patients, transported prior to the ketamine protocol. The comparison group was chosen by matching the ketamine group to more than double the number of non-ketamine patients. Records were obtained from two separate trauma centers. Our primary outcome was documentation of “ketamine-related dissociation” by either the pre-hospital, emergency department or trauma provider. Secondary outcomes included emergency department length of stay and intensive care unit admission. Results Seventy-nine patients received ketamine with records available for analysis. One hundred ninety-three non-ketamine patients were compared to this group. There were nosignificant differences between the two groups in regards to age, weight, gender, or mechanism of injury. The injury severity score was higher in the ketamine group. Nine patients (11%) had documented dissociation after ketamine, with six of these patients back to baseline mentation by arrival to the emergency department. The emergency department length of stay was shorter in the ketamine group. The rate of intensive care unit admission was the same between both groups. Conclusions Pre-hospital sub-dissociative ketamine in geriatric trauma patients is associated with brief episodes of dissociation in a small minority of patients.
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Robinson EJ, Watanabe BL, Brown LH. Ketamine for Prehospital Pain Management Does Not Prolong Emergency Department Length of Stay. PREHOSP EMERG CARE 2020; 25:753-760. [DOI: 10.1080/10903127.2020.1819493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Vanolli K, Hugli O, Eidenbenz D, Suter MR, Pasquier M. Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service. Wilderness Environ Med 2020; 31:385-393. [PMID: 32912718 DOI: 10.1016/j.wem.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. METHODS The survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. RESULTS Ketamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg·kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1-2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. CONCLUSIONS Ketamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.
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Affiliation(s)
- Katia Vanolli
- Medical School of the University of Lausanne, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David Eidenbenz
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marc R Suter
- Department of Anesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Algın A, Yıldırım Ç, Hökenek NM. The Use of Ketamine in Trauma Patients. ANKARA MEDICAL JOURNAL 2019. [DOI: 10.17098/amj.652006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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