Ketamine emergence phenomenon (EMS worker w/question here)

[StarMedic552]

So I work on an ambulance. We carry ketamine and frankly our medical director (a D.O.) loves it. All the other medics hate it though, so I've never seen it used. I know the dosing profiles we use (25mg for pain control, 0.5-1mg for conscious "sedation," like if we have to extricate you from a car and every bone in your body is broken, and the entire vial for intubating someone). I also know this medicine has an emergence phenomenon, but nobody I've ever talked to has experienced it. Can anyone who's used it tell me what the patient is going through while they're in the conscious sedation/totally zonked state, and what happens in the emergence reaction? Also, if my patient comes out of their partial/total dissociation, and has one of these reactions, what should I, as the healthcare provider, do to help? I'd ask the guys I work with but, again, they don't know shit bc this is a recent change and they'd rather give fentanyl (pain) or midazolam (sedation). Thanks in advance.

 

[Chris Timothy]

I've heard a talk once at the Breaking Convention in London about a girl who lost her leg in an accident, got administered ketamine, and had the most profound introspective experience of her life, despite having just lost her leg. Unfortunately I can't find it online, it's exactly what you're looking for I imagine.

The experience itself is notoriously resistant to description. It's sometimes compared to a near-death experience, viewing the world as a, figuratively, completely blank slate, with the feeling that nothing in the universe is out of place. It can both be terrifying and valuable, as normally subconscious processes are brought into consciousnes. Because of this, and despite being quite out there, the patient might accurately sense their state of mind is perceived as a treat to others (or nuisance, just some phenomenon that emerges). This will add to the distress, then again, you're doing your job, and since it's not a self-imposed experience it's expected to be confusing by default. Nor can you be expected to honestly empathize with an experience you're not familiar with.

Why do all the other medics hate ketamine? Are the unwanted side-effects that common?

 

[StarMedic552]

It's a relatively new drug in our kits. We've had morphine and fentanyl for years, and that's what they know, so you get these old paramedics who are like "I know what works and what doesn't and I'm not leaving what I know." Some of them are scared of it raising intracranial pressure, but that was based on a study in the 70s where the patients ALREADY had increased ICP and it's been proven since that you can still give it in a head trauma. It also can increase secretions, but that's easily managed with a little bit of atropine.

As for me, though, I think ketamine has so much upside to it. It increases HR and stroke volume so if a person is nearing shock or is in shock (think mega-trauma, someone who's got pneumonia with a BP of 86 over trash, etc.), it can increase perfusion so much better. It's a bronchodilator, so if we have to intubate someone it'll help them breathe better. It doesn't knock out the respiratory drive unlike opioids/benzodiazepines.

I'm reminded that I did see it one time (I was high when I typed that out so I was a little hazy earlier lol), but it was just a baby dose of like 20mg for a septic patient who had some pain and her BP was 92/terrible so we couldn't give her morphine. We gave her ketamine instead and it brought her BP up to 136, and she stopped trying to pull out a nasogastric tube that the hospital had placed (it was a transfer to an ICU at a different hospital).

But let's say you gave yourself enough to fall into the K-hole. When you came back to reality, would you be freaking out a bit or something? That's what they're talking about with the emergence reaction, and that's what my main question is about

 

[Grigore]

I'd say they should shout a big ''thank you'' to medics like you for administering free ketamine.

That thing is quite a pain in the ass to find nowadays so a little bit of gratitude goes along very well.

 

[Vastness]

As far as the experience goes, I can't comment personally (fortunately) on what it would be like to experience dissociation while undergoing something physically quite traumatic (like the car-extrication scenario you described), but depending on dosage and probably the patient's personality and/or individual neurochemistry they might experience anything from completely serene acceptance of the situation to significant bewilderment and confusion (even if not actual fear or panic in the vast, vast majority of cases).

I would imagine that medically administered doses are always going to be sufficient that the patient physically lashing out is not going to be an issue (or is going to be very easily manageable) but the degree to which the patient is actually dissociated from the external world might vary somewhat - by which I mean, although physical anaesthesia is all but a guarantee, some people may maintain sufficient lucidity to be able to see and interpret to some extent what is going on around them, while others may be mentally just somewhere else, retaining little to no understanding of where they really are or what is really happening around them. That said, it's possible these effects are more dosage dependent that I realise, I am largely speaking from my own experience and the experience of medically administered dosages may be qualitatively different in some ways due to both dosage and method of administration. However in my own experience my understanding of spoken language is the last thing to be affected, and is usually retained even when the ability to correctly interpret other sensory inputs is lost, so on that basis, in response to your enquiry...

if my patient comes out of their partial/total dissociation, and has one of these reactions, what should I, as the healthcare provider, do to help?

I would imagine that the best thing you could do here would be the sort of thing that I'm sure you are already doing as a medical professional, especially one trained in responding to emergency situations. Just make sure to reassure the patient that they are under the influence of something and that they are in safe hands, and that they do not need to be overly concerned about anything for the moment. You can probably even ask them simple questions if you need to, as long as you are very patient with them, although you may or may not get any kind of coherent response.

Also, just be aware that even if it does not seem obvious that they are listening or understanding to what you are saying, it is very possible that they can still hear and understand your voice... so I can imagine that if the experience was completely new and alien to someone, they might be very grateful to hear something reassuring even if the source of this reassurance is unclear and even if they are not able to coherently respond.

 

[Chris Timothy]

But let's say you gave yourself enough to fall into the K-hole. When you came back to reality, would you be freaking out a bit or something? That's what they're talking about with the emergence reaction, and that's what my main question is about

That's a good question, because it's a seeming paradox that people freak out while dissociatives have this reputation of reliably killing fear.

It's exactly because the peek experience reliably kills fear that normally frightful content can be loaded into consciousness even easier than with the psychedelics. So you can dig deeper if you're looking for something... but then of course your everyday consciousness needs to deal with it somehow afterwards. More frightful thoughts can be accessed.. be it memories of old, information about the nervous system and the attached universe itself, or the perceptual basis beneath social narrative has suddenly began outweighing the latter. Hallucinations can be later dismissed as such, so it doesn't matter when hospital staff puts those down. But it can save a patient trouble later on if it's acknowledged early on that there might have been something worthy of personal investigation amongst the experiences. Perhaps radiating this level of understanding can calm the patient in the moment as well.

 

[moscatel]

So I work on an ambulance. We carry ketamine and frankly our medical director (a D.O.) loves it. All the other medics hate it though, so I've never seen it used. I know the dosing profiles we use (25mg for pain control, 0.5-1mg for conscious "sedation," like if we have to extricate you from a car and every bone in your body is broken, and the entire vial for intubating someone). I also know this medicine has an emergence phenomenon, but nobody I've ever talked to has experienced it. Can anyone who's used it tell me what the patient is going through while they're in the conscious sedation/totally zonked state, and what happens in the emergence reaction? Also, if my patient comes out of their partial/total dissociation, and has one of these reactions, what should I, as the healthcare provider, do to help? I'd ask the guys I work with but, again, they don't know shit bc this is a recent change and they'd rather give fentanyl (pain) or midazolam (sedation). Thanks in advance.

The patients gets into a kind of psykosis and its a terrifying experience for them as they are fully awere of what just happend. Leading them to not wanting to be redosed.


To avoid this from happening one should comfort them as much as possible before giving them ketamine. This is easy to forget but its really important.
If they are terrified and anxious before given ketamine the feeling will multiple many times leading them to have the worst experience of a lifetime.


One lady had her fingers cut of by a lawnmover.she was in a lot of pain and really scared. Everybody wanted to help with the pain as soon as possible.Instead of taking the time to calm her down a bit. inform that she would be given a painmed that would help with her pain and insure her of that she would be taken good care of and so on.


The result was that all of her fear multiplied and she had a psykotic reaction. The duration of the drug is not that long but she had the worst 15 -20 min of her life. When she came out of it she would not be redosed.she prefered the pain. She was fully awere of what had happend and she didnt want to go through it again.


On the other hand. If comforted and given a positive thought of beeing taken good care of and that this will help alot with the pain the good feeling will multiply and lead to great patientsatifaction.


One kid going into surgery were told to think of something he loved before given ketamine.
When he was in recovery he turned into a maniac.5 adults to hold him down.he was kicking and screaming and beeing wild.
When fully awake he was asked what he was thinking of. Turns out he was thinking of soccer which he loved and that he had thought he was playing a game of soccer...


This is only 2 examples to show how important it is to make the patient comfortable and as positive as possible before administer ketamine.if you suxeed in that there will be no such adverse efects.


Ketamine is great for surgical pain.
Great advantage that it actually increase BP compared to morphine/fentanyl which often cant be given after acidents due to already low BP due to injury.
But need to make sure that there is not any kind of headinjury or angina involved.


I think that Midazolam should not be used as much as its now done.
If the patient is calmed down, comforted and given painrelieve.
Typically they say that the patient was anxious and needed midazolam to calm down and that its good for them. I think that it is mistreatment in the way that midazolam is not a painkiller but a sedative.
Yes the patient gets calm. But might still be in a lot of pain. But since they have gotten midazolam you have to be carefull with the morphine/fentanyl to avoid adverse efects like resp depresion and lower BP. I have seen a lot of times that the patient then needs to suffer still with a lot of pain bc one can not give anymore morphine/fentanyl at that time bc of increased adversed efects.
Its my opinion that pain makes the patient anxious. And there is a lot of undertreatment when it comes to pain.
They will be calm if given proper painrelief.and then midazolam is no longer needed.


But on the other hand..if you are doing a repo of a broken ankel, leg and so on, the midazolam combined with morphine/fentanyl would be great as the muscles and ligaments gets more relaxed and then its easier and less painfull to do the repo.


I have seen patients wanting to walk with a broken foot after given ketamine. Feeling no pain at all.so hence its inportant to inform them beforehand to take it easy.tell them it works so well that they can actally forget their injury.that will also in addition give them a possitive attitude towards the treatment and prevent psykosis.


Paramedics hate changes. But hopefully your co workers will see how great ketamine is working once they start using it.

 

[jpgrdnr]

There should be journal articles relating to ketamine and trauma as to my knowledge its use is quite common. I've experienced dissociation three times in my life not on ketamine and recovery has just been to let the patient do whatever. Music helps.

RESULTS:
A total of 745 prospective data collection records were available for analysis over the 5 year period. Of all, 93 (12.5%) children cried on awakening when recovering from PPS, 291 (39%) experienced pleasant altered perceptions and 16 (2.1%) experienced what was called 'emergence delirium'. None required any active treatment and all except one settled within 20 min. There was no evidence of an increased rate of nightmares on telephone follow up in the weeks post procedure.

Wouldn't recovery be related to the charge nurse (who does jack shit unless poked with a sharp stick)?

By the time ED hits, EMS should be out of the picture I would think.

----------------
low dose haloperidol? i/v
http://www.glenatlasmd.com/download/13 ARTICLE 65- 67 - Haloperidol for the treatment1.pdf

 

[StarMedic552]

There should be journal articles relating to ketamine and trauma as to my knowledge its use is quite common. I've experienced dissociation three times in my life not on ketamine and recovery has just been to let the patient do whatever. Music helps.



Wouldn't recovery be related to the charge nurse (who does jack shit unless poked with a sharp stick)?

By the time ED hits, EMS should be out of the picture I would think.

----------------
low dose haloperidol? i/v
http://www.glenatlasmd.com/download/13 ARTICLE 65- 67 - Haloperidol for the treatment1.pdf

We don't carry Haldol. Even our patients who have gone batshit crazy get Ketamine (like our excited delirium protocol is 5mg/kg IM or the entire vial, whichever you get to first. In practice, they get 500mg of ketamine and a quick trip to the closest ER. I myself haven't done that though).

In theory, yes we should be out of the picture, but we live in a rural area. If we get a mega trauma and the birds aren't flying, it's a 45 minute drive lights and sirens to the level one trauma centers in Indianapolis, so its possible that we would have to either redose or deal with a confused patient. I'll have to check the research, I haven't found much about emergence delirium but I've found plenty about the dosing.

 

[StarMedic552]

The patients gets into a kind of psykosis and its a terrifying experience for them as they are fully awere of what just happend. Leading them to not wanting to be redosed.


To avoid this from happening one should comfort them as much as possible before giving them ketamine. This is easy to forget but its really important.
If they are terrified and anxious before given ketamine the feeling will multiple many times leading them to have the worst experience of a lifetime.


One lady had her fingers cut of by a lawnmover.she was in a lot of pain and really scared. Everybody wanted to help with the pain as soon as possible.Instead of taking the time to calm her down a bit. inform that she would be given a painmed that would help with her pain and insure her of that she would be taken good care of and so on.


The result was that all of her fear multiplied and she had a psykotic reaction. The duration of the drug is not that long but she had the worst 15 -20 min of her life. When she came out of it she would not be redosed.she prefered the pain. She was fully awere of what had happend and she didnt want to go through it again.


On the other hand. If comforted and given a positive thought of beeing taken good care of and that this will help alot with the pain the good feeling will multiply and lead to great patientsatifaction.


One kid going into surgery were told to think of something he loved before given ketamine.
When he was in recovery he turned into a maniac.5 adults to hold him down.he was kicking and screaming and beeing wild.
When fully awake he was asked what he was thinking of. Turns out he was thinking of soccer which he loved and that he had thought he was playing a game of soccer...


This is only 2 examples to show how important it is to make the patient comfortable and as positive as possible before administer ketamine.if you suxeed in that there will be no such adverse efects.


Ketamine is great for surgical pain.
Great advantage that it actually increase BP compared to morphine/fentanyl which often cant be given after acidents due to already low BP due to injury.
But need to make sure that there is not any kind of headinjury or angina involved.


I think that Midazolam should not be used as much as its now done.
If the patient is calmed down, comforted and given painrelieve.
Typically they say that the patient was anxious and needed midazolam to calm down and that its good for them. I think that it is mistreatment in the way that midazolam is not a painkiller but a sedative.
Yes the patient gets calm. But might still be in a lot of pain. But since they have gotten midazolam you have to be carefull with the morphine/fentanyl to avoid adverse efects like resp depresion and lower BP. I have seen a lot of times that the patient then needs to suffer still with a lot of pain bc one can not give anymore morphine/fentanyl at that time bc of increased adversed efects.
Its my opinion that pain makes the patient anxious. And there is a lot of undertreatment when it comes to pain.
They will be calm if given proper painrelief.and then midazolam is no longer needed.


But on the other hand..if you are doing a repo of a broken ankel, leg and so on, the midazolam combined with morphine/fentanyl would be great as the muscles and ligaments gets more relaxed and then its easier and less painfull to do the repo.


I have seen patients wanting to walk with a broken foot after given ketamine. Feeling no pain at all.so hence its inportant to inform them beforehand to take it easy.tell them it works so well that they can actally forget their injury.that will also in addition give them a possitive attitude towards the treatment and prevent psykosis.


Paramedics hate changes. But hopefully your co workers will see how great ketamine is working once they start using it.

Midazolam is great for seizures and great for keeping someone down after you've intubated them, but not much else. I worked with someone who knocked a patient down with Versed to cardiovert him, but gave no pain medicine. Patient didn't remember it, but he was in so much pain when he came to. I about threw the medic off his own ambulance I was so pissed.

Thanks for the practical advice on how to coach my patient before I give it to him. I care about my patients and want to give them the safest and most effective care. And if I get to be seen by my "dinosaur" partners (who give no pain medicine if SBP is below 90 and scorn the thought of ketamine) as an outside-the-box medic, and if the D.O. sees me as an innovator and skilled with all the tools in my toolbox, well, that's just a plus on top of the satisfaction of providing top notch patient care when they need it the most.

Would Ketamine for pain plus a dash of midazolam for anxiety/amnesia be prudent in the super stressful situations?

 

[StarMedic552]

I'd say they should shout a big ''thank you'' to medics like you for administering free ketamine.

That thing is quite a pain in the ass to find nowadays so a little bit of gratitude goes along very well.

???

It's less paperwork for me lol. When compared to having to explain why I either pushed 10mg of morphine and 300mcg of fentanyl, or having to explain why he asked for pain relief and got nothing, that is. We don't carry ketorolac, so our only options are controlled substances. Fentanyl burns off too quickly for my tastes, morphine just makes you puke all over my truck, and we don't carry Dilaudid/Demerol/Pentazocine.

 

[jpgrdnr]

You don't carry Haldol? Jesus wept. If you have midazolam then that seems a good goto as I thought it was mentioned using it in surgery recovery. Or you can co-administer midazolam and the ket.
https://www.annemergmed.com/article/S0196-0644(10)01536-2/pdf

 

[psy997]

Would Ketamine for pain plus a dash of midazolam for anxiety/amnesia be prudent in the super stressful situations?

Yes, definitely. Having experience with both that would be a great combination for super stressful situations.

I appreciate the level of care and concern you have for your patients, StarMedic. Thank you