Prehospital Ketamine – Is there anything it can’t do?
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Transcript of Prehospital Ketamine – Is there anything it can’t do?
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Pre-hospital ketamine -Is there anything it can’t do?
Per P. Bredmose Director of Training Consultant in Prehospital and retrieval medicine Consultant anaesthetist/intensivist Air Ambulance Department Oslo University Hospital
@VikingOne_
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@VikingOne_No conflicts of interest
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Plan
Ketamine How do we use it - «ketamine staircase» What are the pitfalls?
«Do not try this at home....»
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Forms
R – ketamine (racemic)
S – ketamine
Know YOUR local drug form
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High dose dissociation
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Graded use...
Ketamine starway to full dissociation....
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Dose Range
0.1 mg/kg iv
3 mg/kg iv
(to 10 mg/kg IM)
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Smaller doses for sedation
Hypnosis FIRST Then dissociation
For the co-operating awake patient
BZ Propofol
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RSI
«Upper-end» doses for RSI !
BEWARE : Titrated to patient physiology
Adult: 30-300 mg iv !!
THINK and BE AWARE !
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CONFLICT
Ketamine RSI for the compromised patient
Why on f..k earth use benzodiazepines/propofol to block endogenous symphathetic response ???
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Agitated patient
GET CONTROL
IV IM
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Head Injury
YES you can do it...
That’s fine! --------------------------------------------- Continued anaesthesia
YES
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Barking MAD ONES
SAFE transport of psychiatric patients when needed
+
BZ/Propofol
YES
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Asthma
YES
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Really sick babies
Sepsis Congenital heart disease Diaphragmatic Hernias
Cardiomyopathy
YES
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YES
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However...
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Apnoea
Short lasting apnoea
Sick patients:Longer lasting apnoea !!
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Beware
Reduced stroke volume Cardiac depressant
Increases mainly BP via alfa-receptors Constriction and tachycardia
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Anaesth Intensive Care 1997 Jun;25(3):255-9.
• Following sedation with midazolam (0.15 +/- 0.07, mg.kg-1.h-1) and sufentanil (0.88 +/- 0.33 microgram.kg-1.h-1), patients with impaired left ventricular function (left ventricular ejection fraction area 30 +/- 7%) were randomly assigned to receive ketamine (2.5 +/- 0.9 mg.kg-1.h-1) and midazolam (Group A) or remained on sufentanil/midazolam (Group B). Haemodynamic measurements were performed throughout the first 24 hours after randomization. In group A cardiac index decreased by 21% (P = 0.01), mean arterial pressure increased by 13% (P = 0.01), mean pulmonary artery pressure by 14% (P = 0.04), pulmonary capillary wedge pressure by 20% (P = 0.03), and systemic vascular resistance index by 38% (P < 0.001). No significant cardiovascular effects were observed in Group B. Neither group had significant changes of exogenous catecholamine requirement. In conclusion, ketamine exhibits potential negative cardiovascular effects in patients with catecholamine-dependent heart failure. Therefore, ketamine should not be considered a first line drug for longterm sedation of patients with impaired left ventricular function.
Impaired LV Sedation with KETAMINE and MIDAZOLAM
BP (MAP) ↑ 13 %
----- ----- ----- -----
Cardiac index ↓ 21 %
PAP MAP ↑ 14 %
Wedge pressure 14 %
SVRI ↑↑ 38 %
Reduced CO Increased wordload
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ROSC
Tachycardia ↓ Diastolic time ↓ Coronary perfusion ↑↑ Myocardial demand...
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Sub Arachnoid Hemorrhage
BP 188/129
Don’t go there !
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HYPERTENSIVE PATIENTS
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And the team..
Warn team Warn others Warn family Warn hospital
Ketaminised patients look different.....
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In conclusion....
Be familiar with your drug Know and acknowledge physiology Dose depending on patient Be familiar with your drug
1. Hypertensive patients 2. ROSC 3. Remember info to those around you
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Pre-hospital ketamine Is there anything it can’t do?
Well....there are certainly things where it seems to be less optimal
But under many circumstances it is brilliant !!
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Pre-hospital ketamine -Is there anything it can’t do?
Per P. Bredmose Director of Training Consultant in Prehospital and retrieval medicine Consultant anaesthetist/intensivist Air Ambulance Department Oslo University Hospital
@VikingOne_
![Page 33: Prehospital Ketamine – Is there anything it can’t do?](https://reader031.fdocuments.us/reader031/viewer/2022021919/5871a4d41a28ab044e8b7d09/html5/thumbnails/33.jpg)
?Thank you!