UNCONTROLLED WHEN PRINTED
Introduction
  • Wafer onset: 3-10 minutes

Pharmacology Review

  • Rapid acting dissociative anaesthetic
  • IM onset: 5-10 minutes
  • IV onset: 1 minute

Pharmacology Review

Indications
  • Oral wafer: Second line agent for moderate to severe, acute onset pain in patients >12 years where first line agents have failed to provide adequate relief
  • IV: Second line agent for severe pain of traumatic origin post IV Fentanyl administration. ASMA consult needed if IV Fentanyl minimum dose (age dependent as per CPG) has not been given prior to IV Ketamine administration.
  • IM: First line agent for severe pain of traumatic origin should other means of administering pain medication not be available
  • Combative Traumatic Brain Injury
  • (RASS 4) First line agent for severely disturbed or abnormal behaviour where there is an immediate risk to safety and rapid tranquilisation is required.
Contraindications
  • Hypersensitivity
  • Active cardiovascular disease including cardiac chest pain, heart failure, severe or poorly controlled hypertension
  • Patients with delayed transfer of care (i.e. 'ramped')
  • Oral wafer: Age <12 years
  • Disturbed and abnormal behaviour CLEARLY not RASS 4 for first line agent choice
  • Non traumatic pain (IM / IV / IO)
  • Age <1 Year of age
Precautions / Notes
  • Use with caution in patients with stable psychiatric disorders such as Schizophrenia
  • Use with caution in patients with hyperthyroidism or receiving thyroid replacement due to increased risk of hypertension and tachycardia.
  • Wafer can be administered to patients experiencing non-traumatic pain where methoxyflurane has proven to be ineffective or cannot be administered.
  • Prior to administration of the Ketamine Wafer, patients should be encouraged to rinse mouth with water and swallow completely.
  • Wafer should be placed posterior towards the base of the tongue and medially on either side of the frenulum in the sublingual space.
  • Used with caution in patients with stable psychiatric disorders such as Schizophrenia
  • Sedation of any patient <16 years of age – should prompt a prior ASMA consult wherever practicable
  • Have a low threshold to consult with ASMA where repeat or maintenance doses are required for sedation
  • SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS <0)
  • Use with caution in patients with hyperthyroidism or receiving thyroid replacement due to increased risk of hypertension and tachycardia.
  • Analgesia - IV Fentanyl minimum dose (age dependant as per CPG) should be given prior to IV Ketamine administration
Management
Analgesia
For Prehospital use only

Adult:

  • IM (pre-hospital only):
    • Initial dose: 1 mg/kg;
    • Subsequent doses at 5 minute intervals – 0.5 mg/kg;
    • Concentration: 200 mg/2ml = 100 mg/ml
  • IV/IO (pre-hospital only):
    • Initial dose: 10-20 mg (1-2 ml) administered over at least 1 minute
    • Subsequent doses at 5 minute intervals – 10 mg (1 ml)
  • Oral Wafer:
    • Initial dose: 2x 25mg wafers (50mg total)
    • Subsequent doses at 5 minute intervals: 1x 25mg wafer
    • Administer up to 3x subsequent doses (max total administration: 125mg)
    • Contact CSPSOC if additional analgesia required

Paediatric:

  • IM (pre-hospital only):
    • Initial dose: 1 mg/kg;
    • Subsequent doses at 5 minute intervals – 0.5 mg/kg;
    • Concentration: 200 mg/2ml = 100 mg/ml
  • IV/IO (pre-hospital only):
    • 0.1 mg/kg administered over at least 1 minute and titrated to effect
    • Repeat at 5 minute intervals as required
Rapid Tranquilisation (RASS 4)
For Prehospital use only

IM:

  • Adult 16 or over
  • Initial dose: 4 mg/kg to a max of 400mg (agreed ideal body weight)
  • IV access obtained as soon as practicable

IV for maintenance of ketamine-induced sedation only:

  • 0.5 mg/kg repeated every 5 - 10 minutes IF REQUIRED
Combative Traumatic Brain Injury (TBI)
For Prehospital use only

IM:

  • Initial dose: 2 mg/kg to a maximum of 200 mg (agreed ideal body weight)
  • IV access obtained as soon as practicable

IV/IO:

  • 0.5 mg/kg repeated every 5-10 minutes IF REQUIRED
Critical Care Paramedic only
Analgesia
Adult (IV/IO):
  • Initial dose: 10-20 mg
  • Subsequent dose 10 -30 mg at > 3min intervals
Paediatric (IV/IO):
  • 12 months initial dose: 0.1-0.2 mg/kg.
  • Repeat >3min intervals
Procedural Analgesia

Adult:

  • IM:
    • 2 mg/kg to a max of 200 mg
  • IV/IO:
    • Initial loading dose: up to 0.5 mg/kg
    • Subsequent dose 10 mg after 2 min
    • Further 10mg doses >1min intervals until adequate sedation is achieved.

Paediatric:

  • IM:
    • As per analgesic dose
  • IV/IO:
    • Initial loading dose: 0.2 mg/kg
    • Subsequent dose 0.1 mg/kg after 2 min
    • Further 0.1 mg/kg doses >1min intervals until adequate sedation is achieved.
Rapid Sequence Induction
Adult/Paediatric Induction (RSI), IV/IO:
  • 2 mg/kg
  • 1 mg/kg if haemodynamically compromised
Infusion
Sedation
  • 0.25mg/kg/hr – 1mg/kg/hr; commence 0.5mg/kg/hr
  • 200mg in 2ml dilute up to 50ml NaCl 0.9%. (4mg/ml)
Analgesia
  • 0.1mg/kg/hr  - 0.5mg/kg/hr Commence lower dose 0.2mg/kg/hr
  • 200mg in 2ml dilute up to 50ml NaCl 0.9%. (4mg/ml)
  • Rate of infusion syringe driver (Ketamine)
Dose10kg20kg30kg40kg50kg60kg70kg80kg90kg100kg
0.1mg/kg/hr 0.25ml/hr0.5ml/hr0.75ml/hr1ml/hr1.25ml/hr1.5ml/hr1.75ml/hr2ml/hr2.25ml/hr2.5ml/hr
0.2mg/kg/hr 0.5ml/hr1ml/hr1.5ml/hr2ml/hr2.5ml/hr3ml/hr3.5ml/hr4ml/hr4.5ml/hr5ml/hr
0.25mg/kg/hr 0.625ml/hr1.25ml/hr1.875ml/hr2.5ml/hr3.125ml/hr3.75ml/hr4.375ml/hr5ml/hr5.625ml/hr6.25ml/hr
0.5mg/kg/hr 1.25ml/hr2.5ml/hr3.75ml/hr5ml/hr6.25ml/hr7.5ml/hr8.75ml/hr10ml/hr11.25ml/hr12.5ml/hr
1mg/kg/hr 2.5ml/hr5ml/hr7.5ml/hr10ml/hr12.5ml/hr15ml/hr17.5ml/hr20ml/hr22.5ml/hr25ml/hr
Finger Thoracostomy
  • 200 mg in 2mL
Special Considerations
  • Blood pressure and pulse frequently elevated
  • Random purposeless movements, muscle twitching and rash are common
  • Hypersalivation
  • Emergence reactions (10%)
  • Transient laryngospasm
  • Transient apnoea or respiratory depression

References
References
Presentation

Oral administration:
25mg sublingual wafer

Intravenous/intraosseous administration:
200mg in 2mL

Ketamine
ketaminewafer
label-ketamine
MUST BE LABELLED
DILUTION

Ketamine for IV / IO Administration:

  • Dilute 200mg in 2ml with 18ml NaCl 0.9% to produce 10mg/1ml
Colour assist:

Discarding unused medication must be witnessed and countersigned by attendant and credible witness.

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