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

Pharmacology Review

  • Rapid acting dissociative anaesthetic
  • IM onset: 5-10 minutes
  • IV onset: 1 minute
  • Use of a sedative agent should never be considered routine. Have a high threshold to offer or administer.

Pharmacology Review

 Indications
  • 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
  • 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
Paramedic only
  • (RASS 4) First line agent for severely disturbed or abnormal behaviour where there is an immediate risk to safety and rapid tranquilisation is required and no other sedative medications have already been administered to this patient
 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')
  • Disturbed and abnormal behaviour that are clearly not RASS 4 or where other sedative agents have already been administered (ASMA authority required)
  • Rapid Tranquilsation ONLY: Age < 16 years old
  • Age < 1 years old
  • Oral wafer: Age <12 years old
 Precautions / Notes
  • 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.
  • Caution in patients with stable psychiatric disorders such as Schizophrenia
  • 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
  • Analgesia for Non traumatic pain (IM / IV / IO) in opioid-dependent patients – consider SOC CSP consult
Sedation warnings
  • Sedation is HIGH RISK – must only be carried out after careful deliberation between officers and must not be based primarily at the request or influence of other agencies on scene (e.g. Police etc.)
  • Positive RASS score does not automatically infer a need to sedate
  • Age <16 years old – sedation should prompt a prior ASMA consult wherever practicable
  • ETOH / Intoxication – apply caution
  • Repeat & Maintenance doses – have a low threshold to consult with ASMA where repeat or maintenance doses are required
  • Monitoring – SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS -2 or below)
  • Positioning – DO NOT transport in supine position (increases risk of laryngospasm from secretions) – transport in lateral position
  • Airway & Breathing – monitor airway and breathing effort, including chest movement closely for signs of impairment. Prepare to support if required
  • Restraint – Prone and/or handcuffed to rear carries excessive risk and MUST NOT occur. Physical restraint in any position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia
  • RASS scores must be agreed and documented
  • Weight – Estimated weight must be agreed before administration of any weight based medicines. This must be documented

The final decision to sedate lies with the most senior clinician on scene

 Preparation

Ketamine for IV / IO Administration:

  • Dilute 200 mg in 2 ml with 18 ml NaCl 0.9% to produce 10 mg/1 ml
 Management
 Weight-based Calculations
 
Clear
 kg 
Mode: 
Weight: 

Select indication

IM Ketamine for Combative Traumatic Brain Injury
Presentation: 200mg:2mL (100mg/mL)
Calculated dose:  in
IV Ketamine for Combative Traumatic Brain Injury
Presentation: 200mg:20mL (10mg/mL)
Calculated dose:  in
IM Ketamine for Rapid Tranquilisation (RASS 4)
Presentation: 200mg:2mL (100mg/mL)
Over 16 years only:
Moderate to severe alcohol intoxication:  in 
Nil to mild alcohol intoxication:  in 
IV Ketamine for maintenance of Rapid Tranquilisation (RASS 4)
Presentation: 200mg:20mL (10mg/mL)
Over 16 years only:
Calculated dose:  in 
IM Ketamine for analgesia
Presentation: 200mg:2mL (100mg/mL)
Initial dose:  in
Repeat dose:  in
IV Ketamine for analgesia
Presentation: 200mg:20mL (10mg/mL)
Calculated dose:  to  in  to  in
Subsequent dose:  to  in  to 
Critical Care
IV Ketamine for Rapid Sequence Induction
Presentation: /mL
Calculated dose:  in
 in
IV Ketamine infusion for Sedation
Presentation: /mL
Calculated dose:  to  ( to ) per hour.
IV Ketamine for IV/IO analgesia
Presentation: /mL
Calculated dose:  to  in  to .
Subsequent dose  to  in  to  at >3min intervals Repeat at >3min intervals
IV Ketamine for Procedural Analgesia
Presentation: /mL
Calculated dose:  in
Subsequent dose  in after 2 min with repeat doses >1min intervals until adequate sedation is achieved.
IV Ketamine infusion for Analgesia
Presentation: /mL
Calculated dose:  to  to

  • 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
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/2 ml = 100 mg/ml
  • IV/IO (pre-hospital only):
    • Initial dose: 5 - 20 mg titrated to effect over at least 1 minute
    • Subsequent doses at 5 minute intervals: 5 - 10 mg titrated to effect

Paediatric:

  • IM (pre-hospital only):
    • Initial dose: 1 mg/kg;
    • Subsequent doses at 5 minute intervals: 0.5 mg/kg;
    • Concentration: 200 mg/2 ml = 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

Administration limited to those with independent authority to practice per the Medications Schedule

IM:

Adult 16 or over 

  • Initial dose (agreed ideal body weight):
    • up to 2 mg/kg repeat if necessary to a maximum cumulative dose of 200 mg in moderate to severe alcohol intoxication OR
    • up to 4 mg/kg repeat if necessary to a maximum cumulative dose of 400 mg in nil to mild alcohol intoxication

Adequate sedation may be achieved with lower doses on a case-by-case basis

  • IV access obtained as soon as practicable:
    • ASMA consult required where IV access is not achieved and further sedation required.

IV for maintenance of ketamine-induced sedation only:

  • 0.5 mg/kg repeated every 5 - 10 minutes ONLY 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

  • 0.25 mg/kg/hr – 1 mg/kg/hr; commence 0.5 mg/kg/hr
  • 200 mg in 2 ml dilute up to 50 ml NaCl 0.9%. (4 mg/ml)

Analgesia

  • 0.1 mg/kg/hr  - 0.5 mg/kg/hr Commence lower dose 0.2 mg/kg/hr
  • 200 mg in 2 ml dilute up to 50 ml NaCl 0.9%. (4 mg/ml)
  • Rate of infusion syringe driver (Ketamine)
Dose10kg20kg30kg40kg50kg60kg70kg80kg90kg100kg
0.1 mg/kg/hr 0.25 ml/hr0.5 ml/hr0.75 ml/hr1 ml/hr1.25 ml/hr1.5 ml/hr1.75 ml/hr2 ml/hr2.25 ml/hr2.5 ml/hr
0.2 mg/kg/hr 0.5 ml/hr1 ml/hr1.5 ml/hr2 ml/hr2.5 ml/hr3 ml/hr3.5 ml/hr4 ml/hr4.5 ml/hr5 ml/hr
0.25 mg/kg/hr 0.625 ml/hr1.25 ml/hr1.875 ml/hr2.5 ml/hr3.125 ml/hr3.75 ml/hr4.375 ml/hr5 ml/hr5.625 ml/hr6.25 ml/hr
0.5 mg/kg/hr 1.25 ml/hr2.5 ml/hr3.75 ml/hr5 ml/hr6.25 ml/hr7.5 ml/hr8.75 ml/hr10 ml/hr11.25 ml/hr12.5 ml/hr
1 mg/kg/hr2.5 ml/hr5 ml/hr7.5 ml/hr10 ml/hr12.5 ml/hr15 ml/hr17.5 ml/hr20 ml/hr22.5 ml/hr25 ml/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
Presentation

Oral administration:
25 mg sublingual wafer

IV / IO / IM administration:
200 mg in 2 mL

Ketamine
ketaminewafer
MUST BE LABELLED
label-ketamine
Settings
Current mode:
Extended Care:
Colour assist:

References
References

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


Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

Version

Issue Date

Expiry Date

Clinical Resources Website

St John Ambulance Western Australia Ltd (ABN 55 028 468 715) (St John WA) operates ambulance and other pre-hospital clinical services. St John WA’s Clinical Resources, including its Clinical Practice Guidelines (Clinical Resources), are intended for use by credentialed St John WA staff and volunteers when providing clinical care to patients for or on behalf of St John WA, within the St John WA Clinical Governance Framework, and only to the extent of the clinician’s authority to practice.

Other users – Terms of Use

The content of the St John WA Clinical Resources is provided for information purposes only and is not intended to serve as health, medical or treatment advice. Any user of this website agrees to be bound by these Terms of Use in their use of the Clinical Resources.

St John WA does not represent or warrant (whether express, implied, statutory, or otherwise) that the content of the Clinical Resources is accurate, reliable, up-to-date, complete or that the information contained is suitable for your needs or for any particular purpose. You are responsible for assessing whether the information is accurate, reliable, up-to-date, authentic, relevant, or complete and where appropriate, seek independent professional advice.

St John WA expressly prohibits use of these Clinical Resources to guide clinical care of patients by organisations external to St John WA, except where these organisations have been directly engaged by St John WA to provide services. Any use of the Clinical Resources, with St John WA approval, must attribute St John WA as the creator of the Clinical Resources and include the copyright notice and (where reasonably practicable) provide a URL/hyperlink to the St John WA Clinical Resources website. 

No permission or licence is granted to reproduce, make commercial use of, adapt, modify or create derivative works from these Clinical Resources. For permissions beyond the scope of these Terms of Use, including a commercial licence, please contact medservices@stjohnambulance.com.au

Where links are provided to resources on external websites, St John WA:

  • Gives no assurances about the quality, accuracy or relevance of material on any linked site;
  • Accepts no legal responsibility regarding the accuracy and reliability of external material; and
  • Does not endorse any material, associated organisation, product or service on other sites.

Your use of any external website is governed by the terms of that website, including any authorisation, requirement or licence for use of the material on that website.

To the maximum extent permitted by law, St John WA excludes liability (including liability in negligence) for any direct, special, indirect, incidental, consequential, punitive, exemplary or other loss, cost, damage or expense arising out of, or in connection with, use or reliance on the Clinical Resources (including without limitation any interference with or damage to a user’s computer, device, software or data occurring in connection with such use).

Cookies

Please read this cookie policy carefully before using Clinical Resources from St John WA.

The cookies used on this site are small and completely anonymous pieces of information and are stored on your computer or mobile device. The data that the cookies contain identify your user preferences (such as your preferred text size, scope / skill level preference and Colour Assist mode, among other user settings) so that they can be recalled the next time that you visit a page within Clinical Resources. These cookies are necessary to offer you the best and most efficient possible experience when accessing and navigating through our website and using its features. These cookies do not collect or send analytical information back to St John WA.

Clinical Resources does integrate with Google Analytics and any cookies associated with this service enable us (and third-party services) to collect aggregated data for statistical purposes on how our visitors use this website. These cookies do not contain personal information such as names and email addresses and are used to help us improve your user experience of the website.

If you want to restrict or block the cookies that are set by our website, you can do so through your browser setting. Alternatively, you can visit www.internetcookies.com, which contains comprehensive information on how to do this on a wide variety of browsers and devices. You will find general information about cookies and details on how to delete cookies from your device. If you have any questions about this policy or our use of cookies, please contact us.

St John Ambulance Western Australia Ltd © Copyright 2020, All Rights Reserved

Terms of Use | Privacy Policy | Copyright Statement & Disclaimer