Moderator EMEDPA Posted January 6, 2015 Moderator Share Posted January 6, 2015 agitated pt with low sat, refusing nebs from medics because she wants nothing blocking her face, etc 0.1 mg/kg of ketamine and she is not only taking albuterol, she's taking it inline through bipap....very impressed. I've always wanted to try this. it relaxes the pt a bit and helps relax smooth muscle in the chest wall so they can move more air. heard about this a few years ago at a conference. this is the bomb. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted January 6, 2015 Share Posted January 6, 2015 I had one the other day who had been intubated EIGHT TIMES for her asthma. EIGHT TIMES!! I used versed to get her to stop fighting the bipap, shoulda used ketamine instead. Didn't even think about it. Next time I will.Managed to get her turned around without tubeing her <whew!> Link to comment Share on other sites More sharing options...
MedicinePower Posted January 6, 2015 Share Posted January 6, 2015 http://www.annemergmed.com/article/S0196-0644%2814%2901365-1/abstract "Patients received a dissociative dose of ketamine, allowing preoxygenation with high-flow nonrebreather mask or noninvasive positive pressure ventilation (NIPPV)." Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 6, 2015 Author Moderator Share Posted January 6, 2015 I had one the other day who had been intubated EIGHT TIMES for her asthma. EIGHT TIMES!! I used versed to get her to stop fighting the bipap, shoulda used ketamine instead. Didn't even think about it. Next time I will. Managed to get her turned around without tubeing her <whew!> I tried ativan first with this lady. did nothing, so moved on to ketamine 10 mg (see was 100kg)+ mag sulfate +bipap. worked very well. will use that cocktail again. Link to comment Share on other sites More sharing options...
RealWayPA Posted March 4, 2015 Share Posted March 4, 2015 Couple of questions: 1) How low was "low sat"? 2) Was she decompensating and, if so, how quickly? 3) In the future, what's your threshold for using ketamine in these pts? At our shop (urban level II), it pains me to see how algorithm-based some of our providers are. We even have some MDs trained at very prestigious East Coast medical schools and EM residencies. Interestingly, one of the most out of the box ER docs is a foreign-trained DO - he's really sharp about using these sorts of less-than-dogmatic approaches to patients. For my part, although I'm still a PA student...I love BiPap. Love it...love it...love it. Seems like it can be used and set up with a vent for just about any imaginable emergency respiratory problem short of total apnea. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 4, 2015 Author Moderator Share Posted March 4, 2015 86% or so on a cannula from the medics(all she would accept) and slowly circling down and very agitated. I'm definitely doing this again for the agitated asthmatic or chfer who won't tolerate bipap. Link to comment Share on other sites More sharing options...
RealWayPA Posted May 31, 2016 Share Posted May 31, 2016 Hi EMEDPA - Sorry it took me so long to respond to this - I was re-reading old posts and just caught something you said: Not sure what your experience has been thus far, but you may want to use ketamine with caution in the CHFer who won't tolerate BiPap. The sympathetic surge associated with ketamine may be a bit untoward in a CHF patient who is already profoundly tachycardic and whose heart is already working triple overtime. What do you think? Link to comment Share on other sites More sharing options...
RealWayPA Posted May 31, 2016 Share Posted May 31, 2016 As an alternative, maybe dexmedetomidine if you have it available? And a captopril or two under the tongue! Link to comment Share on other sites More sharing options...
lightbearer06 Posted June 1, 2016 Share Posted June 1, 2016 How much of a sympathetic surge would you get with 0.1 mg/kg? I wouldn't think it would be clinically significant. Link to comment Share on other sites More sharing options...
RealWayPA Posted June 1, 2016 Share Posted June 1, 2016 LightBearer06 - I think my approach is one of principle rather than degree. Frankly, I have no clue what the actual "numbers" are for ketamine sympathetic surge, but it does happen. However, in principle, isn't it better to use an agent like Precedex that will actively counter the underlying sympathetic overdrive associated with acute CHF exacerbations, rather than contributing to it? Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted June 1, 2016 Share Posted June 1, 2016 Not arguing either way regarding ketamine.... but I don't think most community places are going to have precedex. Something to consider at least. Especially rural places. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted June 1, 2016 Moderator Share Posted June 1, 2016 Having used both extensively, ketamine at sub-induction doses cause little sympathetic surge and precedex is way too expensive as well as being pretty weak. Link to comment Share on other sites More sharing options...
RealWayPA Posted June 1, 2016 Share Posted June 1, 2016 LTJ - thanks for sharing your experience! Link to comment Share on other sites More sharing options...
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