https://doi.org/10.4081/ecj.2024.12166
Four good reasons to choose ketamine in the emergency department. A case series and literature review
Submitted: 8 December 2023
Accepted: 19 January 2024
Published: 1 February 2024
Accepted: 19 January 2024
Abstract Views: 1597
PDF: 551
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Ketamine is a fast-acting N-methyl-D-aspartate (NMDA) receptor antagonist that can be used in a range of clinical scenarios in the pre-hospital setting and emergency department (ED). When compared with other anesthetic agents, ketamine has many unique properties, such as the ability to produce dose-dependent analgesic and anesthetic effects with a wide margin of safety. Ketamine may be used in the ED for sedation, pain management, and acute agitation treatment in the cases of benzodiazepine (BDZ)-resistant alcohol withdrawal syndrome (AWS) and substance use disorder. To highlight the efficacy and safety of ketamine, we reviewed the literature, starting with a description of four different cases of patients who presented to our ED and were treated with ketamine.
Dinis-Oliveira RJ. Metabolism and metabolomics of ketamine: a toxicological approach. Forensic Sci Res 2017;2:2–10.
DOI: https://doi.org/10.1080/20961790.2017.1285219
Riccardi A, Guarino M, Serra S, et al. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023;12:3256.
DOI: https://doi.org/10.3390/jcm12093256
Domino EF, Chodoff P, Corssen G. Pharmacologic effects of ci-581, a new dissociative anesthetic, in man. Clin Pharmacol Ther 1965;6:279–91.
DOI: https://doi.org/10.1002/cpt196563279
Silverstein WK, Juurlink DN, Zipursky JS. Ketamine for the treatment of acute pain. CMAJ 2021;193:E1663.
DOI: https://doi.org/10.1503/cmaj.210878
Corriger A, Pickering G. Ketamine and depression: a narrative review. Drug Des Devel Ther 2019;13:3051–67.
DOI: https://doi.org/10.2147/DDDT.S221437
Frestadius A, Grehn F, Kildal M, et al. Intranasal dexmedetomidine and rectal ketamine for young children undergoing burn wound procedures. Burns 2022;48:1445–51.
DOI: https://doi.org/10.1016/j.burns.2021.08.005
Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth 2011;58:911–23.
DOI: https://doi.org/10.1007/s12630-011-9560-0
Fang Y, Wang X. Ketamine for the treatment of refractory status epilepticus. Seizure 2015;30:14–20.
DOI: https://doi.org/10.1016/j.seizure.2015.05.010
Petrakis IL, Limoncelli D, Gueorguieva R, et al. Altered NMDA glutamate receptor antagonist response in individuals with a family vulnerability to alcoholism. Am J Psychiatry 2004;161:1776-82.
DOI: https://doi.org/10.1176/ajp.161.10.1776
Jones JL, Mateus CF, Malcolm RJ, et al. Efficacy of Ketamine in the Treatment of Substance Use Disorders: A Systematic Review. Front Psychiatry 2018;9:277.
DOI: https://doi.org/10.3389/fpsyt.2018.00277
Springer B. Hyperactive Delirium with Severe Agitation. Emerg Med Clin North Am 2024;42:41–52.
DOI: https://doi.org/10.1016/j.emc.2023.06.011
Morgan MM, Perina DG, Acquisto NM, et al. Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement. Prehosp Emerg Care 2021;25:588-92.
DOI: https://doi.org/10.1080/10903127.2020.1801920
Verma A, Snehy A, Vishen A, et al. Ketamine Use allows Noninvasive Ventilation in Distressed Patients with Acute Decompensated Heart Failure. Indian J Crit Care Med 2019;23:191-2.
DOI: https://doi.org/10.5005/jp-journals-10071-23153
Kiureghian E, Kowalski JM. Intravenous ketamine to facilitate noninvasive ventilation in a patient with a severe asthma exacerbation. Am J Emerg Med 2015;33:1720.e1–2.
DOI: https://doi.org/10.1016/j.ajem.2015.03.066
Riccardi A, Serra S, De Iaco F, et al. Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic. J Clin Med 2023;12:3124.
DOI: https://doi.org/10.3390/jcm12093124
Karim HM, Šarc I, Calandra C, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26:938-48.
DOI: https://doi.org/10.5005/jp-journals-10071-23950
Zanos P, Moaddel R, Morris PJ, et al. Ketamine and Ketamine Metabolite Pharmacology: Insights into Therapeutic Mechanisms. Pharmacol Rev 2018;70:621-60.
DOI: https://doi.org/10.1124/pr.117.015198
Desta Z, Moaddel R, Ogburn ET, et al. Stereoselective and regiospecific hydroxylation of ketamine and norketamine. Xenobiotica 2012;42:1076-87.
DOI: https://doi.org/10.3109/00498254.2012.685777
Hijazi Y, Boulieu R. Contribution of CYP3A4, CYP2B6, and CYP2C9 isoforms to N-demethylation of ketamine in human liver microsomes. Drug Metab Dispos 2002;30:853-8.
DOI: https://doi.org/10.1124/dmd.30.7.853
Peltoniemi MA, Hagelberg NM, Olkkola KT, Saari TI. Ketamine: A Review of Clinical Pharmacokinetics and Pharmacodynamics in Anesthesia and Pain Therapy. Clin Pharmacokinet 2016;55:1059–77.
DOI: https://doi.org/10.1007/s40262-016-0383-6
Sinner B, Graf BM. Ketamine. Handb Exp Pharmacol 2008, p. 313–333.
DOI: https://doi.org/10.1007/978-3-540-74806-9_15
Dayton PG, Stiller RL, Cook DR, Perel JM. The binding of ketamine to plasma proteins: emphasis on human plasma. Eur J Clin Pharmacol 1983;24:825–31.
DOI: https://doi.org/10.1007/BF00607095
Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. J Emerg Med 2018;54:447–57.
DOI: https://doi.org/10.1016/j.jemermed.2017.12.049
Poonai N, Canton K, Ali S, et al. Intranasal ketamine for procedural sedation and analgesia in children: A systematic review. PLoS One 2017;12:e0173253.
DOI: https://doi.org/10.1371/journal.pone.0173253
Choi E-J, Kim C-H, Yoon J-Y, Kim E-J. Ketamine-propofol (ketofol) in procedural sedation: a narrative review. J Dent Anesth Pain Med 2023;23:123–33.
DOI: https://doi.org/10.17245/jdapm.2023.23.3.123
Noppers I, Niesters M, Aarts L, et al. Ketamine for the treatment of chronic non-cancer pain. Expert Opin Pharmacother 2010;11:2417-29.
DOI: https://doi.org/10.1517/14656566.2010.515978
Fabbri A, Voza A, Riccardi A, et al. The Pain Management of Trauma Patients in the Emergency Department. J Clin Med 2023;12:3289.
DOI: https://doi.org/10.3390/jcm12093289
Weber F, Wulf H, Gruber M, Biallas R. S-ketamine and s-norketamine plasma concentrations after nasal and i.v. administration in anesthetized children. Paediatr Anaesth 2004;14:983–8.
DOI: https://doi.org/10.1111/j.1460-9592.2004.01358.x
Buonsenso D, Barone G, Valentini P, et al. Utility of intranasal Ketamine and Midazolam to perform gastric aspirates in children: a double-blind, placebo controlled, randomized study. BMC Pediatr 2014;14:67.
DOI: https://doi.org/10.1186/1471-2431-14-67
Huge V, Lauchart M, Magerl W, et al. Effects of low-dose intranasal (S)-ketamine in patients with neuropathic pain. Eur J Pain 2010;14:387-94.
DOI: https://doi.org/10.1016/j.ejpain.2009.08.002
Oliveira JE Silva L, Lee JY, Bellolio F, et al. Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis. Am J Emerg Med 2020;38:1860–6.
DOI: https://doi.org/10.1016/j.ajem.2020.05.094
Rao LK, Flaker AM, Friedel CC, Kharasch ED. Role of Cytochrome P4502B6 Polymorphisms in Ketamine Metabolism and Clearance. Anesthesiology 2016;125:1103–12.
DOI: https://doi.org/10.1097/ALN.0000000000001392
Visser E, Schug SA. The role of ketamine in pain management. Biomed Pharmacother 2006;60:341–8.
DOI: https://doi.org/10.1016/j.biopha.2006.06.021
Tran KP, Nguyen Q, Truong XN, et al. A comparison of ketamine and morphine analgesia in prehospital trauma care: a cluster randomized clinical trial in rural Quang Tri province, Vietnam. Prehosp Emerg Care 2014;18:257-64.
DOI: https://doi.org/10.3109/10903127.2013.851307
Green SM, Andolfatto G, Krauss BS. Ketamine and intracranial pressure: no contraindication except hydrocephalus. Ann Emerg Med 2015;65:52–4.
DOI: https://doi.org/10.1016/j.annemergmed.2014.08.025
Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014;21:163–73.
DOI: https://doi.org/10.1007/s12028-013-9950-y
Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase of severe traumatic brain injury ‘an old drug for new uses?’. Crit Care 2021;25:19.
DOI: https://doi.org/10.1186/s13054-020-03452-x
Laws JC, Vance EH, Betters KA, et al. Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury. Crit Care Med 2023;51:563-72.
DOI: https://doi.org/10.1097/CCM.0000000000005806
Dyal S, MacLaren R. The Assessment and Management Practices of Acute Alcohol Withdrawal: Results of a Nationwide Survey of Critical Care Pharmacists. Hosp Pharm 2019;54:22-31.
DOI: https://doi.org/10.1177/0018578718769241
Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy 2018;38:139–51.
DOI: https://doi.org/10.1002/phar.2060
Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med 2017;35:1005–11.
DOI: https://doi.org/10.1016/j.ajem.2017.02.002
Strayer RJ, Friedman BW, Haroz R, et al. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023;64:517-40.
DOI: https://doi.org/10.1016/j.jemermed.2023.01.010
Goldfine CE, Tom JJ, Im DD, et al. The therapeutic use and efficacy of ketamine in alcohol use disorder and alcohol withdrawal syndrome: a scoping review. Front Psychiatry 2023;14:1141836.
DOI: https://doi.org/10.3389/fpsyt.2023.1141836
Shah P, McDowell M, Ebisu R, et al. Adjunctive Use of Ketamine for Benzodiazepine-Resistant Severe Alcohol Withdrawal: a Retrospective Evaluation. J Med Toxicol 2018;14:229–36.
DOI: https://doi.org/10.1007/s13181-018-0662-8
Garel N, McAnulty C, Greenway KT, et al. Efficacy of ketamine intervention to decrease alcohol use, cravings, and withdrawal symptoms in adults with problematic alcohol use or alcohol use disorder: A systematic review and comprehensive analysis of mechanism of actions. Drug Alcohol Depend 2022;239:109606.
DOI: https://doi.org/10.1016/j.drugalcdep.2022.109606
Kelson M, Burnett JM, Matthews A, Juneja T. Ketamine Treatment for Alcohol Use Disorder: A Systematic Review. Cureus 2023;15:e38498.
DOI: https://doi.org/10.7759/cureus.38498
Cohen SP, Bhatia A, Buvanendran A, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018;43:521-46
DOI: https://doi.org/10.1097/AAP.0000000000000808
Schwenk ES, Pradhan B, Nalamasu R, et al. Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity. Curr Pain Headache Rep 2021;25:57.
DOI: https://doi.org/10.1007/s11916-021-00977-w
Pourmand A, Mazer-Amirshahi M, Royall C, et al. Low dose ketamine use in the emergency department, a new direction in pain management. Am J Emerg Med 2017;35:918–21.
DOI: https://doi.org/10.1016/j.ajem.2017.03.005
Subramanian S, Haroutounian S, Palanca BJA, Lenze EJ. Ketamine as a therapeutic agent for depression and pain: mechanisms and evidence. J Neurol Sci 2022;434:120152.
DOI: https://doi.org/10.1016/j.jns.2022.120152
Orhurhu VJ, Roberts JS, Ly N, Cohen SP. Ketamine in Acute and Chronic Pain Management. StatPearls 2023.
Childers WE, Baudy RB. N-methyl-D-aspartate antagonists and neuropathic pain: the search for relief. J Med Chem 2007;50:2557–62.
DOI: https://doi.org/10.1021/jm060728b
Serra S, Spampinato MD, Riccardi A, et al. Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach. J Clin Med 2023;12:4357.
DOI: https://doi.org/10.3390/jcm12134357
Goldman N, Frankenthaler M, Klepacz L. The Efficacy of Ketamine in the Palliative Care Setting: A Comprehensive Review of the Literature. J Palliat Med 2019;22:1154–61.
DOI: https://doi.org/10.1089/jpm.2018.0627
Binsaeedu AS, Prabakar D, Ashkar M, et al. Evaluating the Safety and Efficacy of Ketamine as a Bronchodilator in Pediatric Patients With Acute Asthma Exacerbation: A Review. Cureus 2023;15:e40789.
DOI: https://doi.org/10.7759/cureus.40789
Pardue Jones B, Fleming GM, Otillio JK, et al. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma 2016;53:607–17.
DOI: https://doi.org/10.3109/02770903.2015.1067323
Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest 2022;162:747–56.
DOI: https://doi.org/10.1016/j.chest.2022.02.029
Alkhachroum A, Der-Nigoghossian CA, Mathews E, et al. Ketamine to treat super-refractory status epilepticus. Neurology 2020;95:e2286-94.
DOI: https://doi.org/10.1212/WNL.0000000000010611
Lahti AC, Weiler MA, Tamara Michaelidis BA, et al. Effects of ketamine in normal and schizophrenic volunteers. Neuropsychopharmacology 2001;25:455–67.
DOI: https://doi.org/10.1016/S0893-133X(01)00243-3
Coppel DL, Bovill JG, Dundee JW. The taming of ketamine. Anaesthesia 1973;28:293–6.
DOI: https://doi.org/10.1111/j.1365-2044.1973.tb00449.x
Schep LJ, Slaughter RJ, Watts M, Mackenzie E, Gee P. The clinical toxicology of ketamine. Clin Toxicol (Phila) 2023;61:415–28.
DOI: https://doi.org/10.1080/15563650.2023.2212125
Bellolio MF, Gilani WI, Barrionuevo P, et al. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016;23:119-34.
DOI: https://doi.org/10.1111/acem.12875
Green SM, Roback MG, Krauss B, Emergency Department Ketamine Meta-Analysis Study Group. Laryngospasm during emergency department ketamine sedation: a case-control study. Pediatr Emerg Care 2010;26:798–802.
DOI: https://doi.org/10.1097/PEC.0b013e3181fa8737
Morgan MW, Dore E. A Case Report of Opisthotonos Associated with Administration of Intramuscular Ketamine. Clin Pract Cases Emerg Med 2021;5:429–31.
DOI: https://doi.org/10.5811/cpcem.2021.6.53069
Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med 2008;26:985–1028.
DOI: https://doi.org/10.1016/j.ajem.2007.12.005
Maneglia R, Cousin MT. A comparison between propofol and ketamine for anaesthesia in the elderly. Haemodynamic effects during induction and maintenance. Anaesthesia 1988;43:109–11.
DOI: https://doi.org/10.1111/j.1365-2044.1988.tb09090.x
Kanbak M. Ketamine in porphyria. Anesth Analg 1997;84:1395.
DOI: https://doi.org/10.1213/00000539-199706000-00056
How to Cite
Belviso, F., Poggiali, E., Ioannilli, E., Bastoni, D., Stamate, M., Vercelli, A., & Riccardi, A. (2024). Four good reasons to choose ketamine in the emergency department. A case series and literature review. Emergency Care Journal, 20(1). https://doi.org/10.4081/ecj.2024.12166
Copyright (c) 2024 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
