Prescription Drug Abuse

[Eydawn]

I think I've made my views on Ketamine pretty clear...

We've used it as a continuous infusion to treat refractory pain (think: chronic regional pain syndrome, opioid intolerance for postoperative patients) and often give concurrent benzos. My personal experience with it as a nurse has been that it turns my patients into fruit loops who need safety partners to keep them from hopping out of the bed/pulling out IV's/swinging at folks. I find that the dissociative effects really cause more harm than the analgesic effects provide benefit, and I really don't think a busy ER or busy nursing floor is a good environment for it.

As far as the large bone fracture and benzo use, absolutely some valium has been a godsend... most of my folks with displaced femur/humerus fractures have been in so much pain that IV opiates alone haven't touched it, but you add in the valium (and then oral cyclobenzaprine if they're not immediately headed for the OR) and things get a lot more tolerable.

Wendy

CO EMT-B

RN-ADN

[ERDoc]

I think the doses that Kiwi is using it in is much less than you would see in an infusion. It's just enough to take the pain away but not cause altered sensorium.

[Eydawn]

Right... but in patients with unrecognized underlying mental illness, even small doses of ketamine can produce dissociative effects, no?

Like any tool, it has benefits and dangers. I just don't buy the "magic K is the way to go!" line that some seem to have... I've just not seen it work the way it's supposed to...

Wendy

CO EMT-B

RN-ADN

[ERDoc]

Yes, it can cause psychiatric like symptoms in about 12% of the pts.

[paramedicmike]

I read somewhere recently, too, that a little valium can help with the recovery from ketamine. Just make sure they're still breathing through it all.

That being said, even with some pretty wicked emergence reactions, I've not seen this done.

[ERDoc]

For bad emergence reactions we typically use benzos. I've only seen one bad emergence reaction and benzos worked great.

[MariB]

OK personal question here. Besides toradol. What is a great pain reliever that isn't a narcotic? My kid is sick of the narcs. Is there something stronger she can ask about that won't make her dopey? She's going back to finish her nursing degree in January.

[Kiwiology]

Bah, ketamine is the best thing ever, hands down. The Australasian experience across thousands of patients have been overwhelmingly positive with no significant psychotropic problems and only a few isolated cases of hypertension or tachycardia. Of course we are talking "low dose" boluses (10-40 mg at a time) and not the massive infusions people get with CRPS/RSD. The most I have seen (or heard) of somebody getting was 100 mg in small boluses whereas I've seen people getting anywhere from 200-500 mg an hour infusion for CRPS. We are also using it only in a small group of critical care type paramedics. In hospital it is very popular down here in the same fashion for analgesia and is also used in higher doses for disassociation/sedation particularly now to get people on NIV who would otherwise have been tubed in the past.

Tylenol 3, with codine is OTC in Canada? A bunch of my friends are now headed to the Port Authority bus terminal.

It's non Rx here in New Zed as well as the UK and Australia but you might need to buy it at the pharmacy (technically one step up from a GSM - general sale medicine - which is commonly known as "OTC" i.e. you can buy it anywhere).

Some crazy guy tried to beat me up at the Port Authority Bus Terminal ...

[mobey]

Gotta chime in on the Ketamine discussion.

In my opinion I think using Ketamine routinely in the prehospital setting is a little narrow minded. The problem being: most ER's are not going to continue use of Ketamine after EMS leaves. What that means for the patient is at some point (quite quickly) the ketamine will wear off and they will be left writhing in pain until they get assessed by an ER doc and get new orders for a narcotic.... then the loading dose must be administered to reach therapeutic effect- which we all know with personal bias involved, or a really busy ER, can take a long long long time... Then finally at some point they will have pain relief achieved while awaiting further treatment. This just seems like a poor approach to pain control, where on that same patient we could have used the 25mg of morphine to reach the therapeutic effect prior to entering the ER leaving them to just top up on a simple narcotic as the patient needed. Instead too many give 10mg of morphine, call the pain 'refractory' and switch drugs so the patient has quicker pain control while in the ambulance without considering the tertiary care.

This theme is also becoming common with RSI's in this area. People are using Ketamine for the RSI, then followup sedation/analgesia with Fentanyl/Versed. But they wait for the patient to begin waking up so they know most of the ketamine has been used up prior to administering the benzo's and narcotics. Yaya... we can debate neuroprotection, and blood pressure with ketamine all night, but the point i'm making is that every case should be individualized for that specific patient and the health care collaboration they are involved in, not just rubber stamped.

Now don't get me wrong: I do think ketamine has a place for true refractory pain, or opioid sensitivity, but in those cases I DO suspect the ER will continue with it's use.

The reality is, prehospitally we kinda suck at pain relief with narcotics. We tend to stay away from true therapeutic doses either because of protocol, or fear of resp depression or mental status change.

[Kiwiology]

If you're using ketamine in combination with morphine (or fentanyl) you need to be giving a decent dose before deciding its not working; in an adult patient I'd be giving preferably at least 20 mg. I've had people we've put 20 mg into and they sort of blinked and gone "well, have you given me anything yet?"

Ketamine can also be used as a sole agent and we do this a lot in patients who have burns or MSK pain e.g. long bone fractures (particularly femurs).

As for anaesthesia it's just common knowledge that it wears off quickly (~ 15 minutes I think) so you need to be plugging the patient into your post intubation analgesia/sedation/paralysis regimen as soon as you've got them into the ambulance. We use fentanyl, midazolam and rocuronium here.

Now, this whole "ambos give shit analgesia" thing seems to be purely an American thing; not sure about Canada but I've had a quick look at the AHS guidelines and you have up to 20 mg of morphine (or 250 mcg fentanyl) on standing order which is fairly decent, in line with what we have here (we have 40 mg / 200 mcg but that is only because we are physically limited by the amount carried).