ketamine. Ketamine. Ketamine! KETAMINE!!!!
Is there anything the SoMe wonderdrug can not do? I mean, isn’t the answer *always* ketamine?
This is a single center, randomized, prospective parallel study for patients aged 18-70 with moderate to severe acute, traumatic, orthopaedic pain with pain scale >80 on VAS. With about 25 patients per treatment arm, they compared intranasal Ketamine (1 mg/kg), IV morphine (0.1mg/kg), and IM morphine (0.15 mg/kg).
Rule ins: Must have GCS 15, weight 50-110kg, systolic bp 90-160 mmHg, HR <100 bpm.
Rule outs: head trauma, history of regular opiates or psychiatric disorder, analgesia within 3 hours, “a large meal ingested within the previous hour,” any LOC, dizziness, vomiting, or nausea were excluded as well.
The group measured pain scales every 5 minutes for 1 hour, as well as ADRs at end of 1 hour. They deemed a 15 mm score reduction in pain deemed significant.
Time to onset was fastest in the IV morphine route at 8.9 minutes, Ketamine came in second at 14.3 minutes, and IM morphine, unsurprisingly, brought up the rear with 26 minutes. The time of onset between Ketamine and the two morphine routes was insignificant, though the time to onset between IM and IV morphine was statistically significant. Also not surprisingly, Ketamine had significantly higher ADRs (difficulty concentrating 58% vs ~21%, confusion 50% vs ~15%). While pain reduction at one hour was similar across all treatments, there was a trend for decreased patient satisfaction with Ketamine (58% satisfaction vs ~70% with morphine – this was not statistically significant).
While I would love to say this trial adds to the data for usage of Ketamine… not quite. It really does not look at the patients for which we would **want** to use ketamine – namely, say those with poor access that an IN analgesic may work wonders; those with an opiate habit; and seriously, what trauma patient doesn’t come in a bit tachycardic? And while yes, the results are about in line with what we’ve seen in the past and sort of come to expect (reasonable analgesia, somewhat decreased patient satisfaction, higher ADRs) this just is not a real world study that we can point to and say, “this is why we need IN Ketamine in our protocols.”