Ketamine

Aliases: Ketalar 

Indications: Pain, Severe bronchospasm, Procedural sedation, Rapid sequence induction, Excited delirium, Lifesaving procedure    

Contraindications: Uncontrolled Hypertension, Hypersensitivity.  Be cautious administering to older adults and elderly. 

Concentrations: 

Injection: 10mg/mL

Injection: 100mg/mL

Dosing

Max dosing not to be exceeded during a single encounter without discussion with Medical Control.

Adult:

Indication	Dose	Route	Note
-Pain -Severe bronchospasm	0.2 mg/kg (Max: 10 mg)	IV infusion over 10 minutes	-If the patient is hemodynamically unstable, defined as MAP < 65 and/or respiratory failure, then ketamine may be used first for pain.  -If the patient is hemodynamically stable, defined as MAP > 65 and no respiratory failure, then the appropriate amount of fentanyl (up to 100 mcg) should be administered first; then ketamine can be administered x 1 10 minutes later if no relief in pain has occurred.
-Pain -Severe bronchospasm	0.4 mg/kg (Max: 50 mg)	IM	-If the patient is hemodynamically unstable, defined as MAP < 65 and/or respiratory failure, then ketamine may be used first for pain.  -If the patient is hemodynamically stable, defined as MAP > 65 and no respiratory failure, then the appropriate amount of fentanyl (up to 100 mcg) should be administered first; then ketamine can be administered x 1 10 minutes later if no relief in pain has occurred.
-Procedural Sedation  -Alcohol Withdrawal  -Refractory Status Epilepticus	1 mg/kg (Max: 100 mg)	Slow IV Push	-May repeat every 2 minutes PRN  -Consider 50 mg increments for hypotensive patients to achieve sedation without CV collapse
Rapid Sequence Induction	2 mg/kg (Max: 200 mg)	Slow IV Push	-May repeat every 2 minutes PRN  -Consider 50 mg increments for hypotensive patients to achieve sedation without CV collapse
-Severe Agitation/Excited Delirium  -Lifesaving Procedure	4 mg/kg (Max: 500 mg)	IM	-Lifesaving procedure when IV/IO access cannot be obtained.

Pediatric:

Indication	Dose	Route	Note
-Pain -Severe bronchospasm	0.2 mg/kg (Max: 10 mg)	IV infusion over 10 minutes	Must be >3 months old and see pediatric dosing chart for patient weight minimums.
-Pain -Severe bronchospasm	0.4 mg/kg (Max: 25 mg)	IM	Must be >3 months old and see pediatric dosing chart for patient weight minimums.
-Procedural Sedation  -Refractory Status Epilepticus  -Severe Agitation/Excited Delirium  -Lifesaving Procedure	1 mg/kg (Max: 100 mg)	Slow IV Push	Must be >3 months old and see pediatric dosing chart for patient weight minimums.
-Procedural Sedation  -Refractory Status Epilepticus  -Severe Agitation/Excited Delirium  -Lifesaving Procedure	4 mg/kg (Max: 500 mg)	IM	Must be >3 months old and see pediatric dosing chart for patient weight minimums.
Rapid Sequence Induction	2 mg/kg (Max: 200 mg)	Slow IV Push	Must be >3 months old and see pediatric dosing chart for patient weight minimums.

Precautions: Laryngospasms and other forms of airway obstruction have occurred. Use with caution in patients with a history of Schizophrenia. Be aware that in lower dosing some patients may experience partial dissociation. 

Adverse/Side Effects: Respiratory depression may occur, Laryngospasms, Hypertension, Emergence Reactions (Hallucinations, Delirium), dizziness, nausea, vomiting  

Class: Ketamine hydrochloride is a rapid-acting dissociative anesthetic.   

Mechanism of Action: The anesthetic state produced by ketamine hydrochloride has been termed “dissociative anesthesia” in that it appears to selectively interrupt association pathways of the brain before producing somesthetic sensory blockade. It may selectively depress the thalamoneocortical system before significantly obtunding the more ancient cerebral centers and pathways (reticular-activating and limbic systems). 

Onset of Action	Peak Effect	Duration of Action
< 30 secs (IV)   3-15 mins (IM)	Fast (IV)   5-30 mins (IM)	IV Anesthetic: 5-10 mins  IM Anesthetic: 12-25 mins  Analgesia: 15-30 mins