Hot off the press: Clinical practice guideline for ketamine in the ED

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.



Hhhmmmm...how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.

This practice guideline was updated from a previous 2004 version because of new research that proved/disproved the way ketamine was being utilized. It was compiled by four physicians that are experts in the field of ketamine sedation, two of which wrote the 2004 practice guideline. Updated research was found by performing a MEDLINE search from January 2003 to November 2010 using the search term "ketamine".

Highlights:



1. Adults have been included in the 2011 guidelines.



2. Adjunctive medications

• Prophylactic ondansetron can help reduce vomiting. The number needed to benefit = 9.
• No need to co-administer atropine or glycopyrrolate for oral secretions.
• Prophylactic midazolam 0.3 mg/kg may prevent recovery reactions in adults (but not children). The number needed benefit = 6.

3. Contraindications

• Age < 3 months because of risk of airway complications
• Known or suspected schizophrenia (even if currently stable)
• Head trauma has been removed as a contraindication.

4. Route of administration

• IV administration appears to be preferred over IM, because of faster recover and fewer episodes of emesis.
• IV route: Peak concentration and onset = 1 min, duration of dissociation = 5-10 min, time from dose-to-discharge = 50-110 min
• IM route: Peak concentration and onset = 5 min, duration of dissociation = 20-30 min, time from dose-to-discharge = 60-140 min 

5. Complications

• Laryngospasm has been reported to be around 0.3%. What do you do when this happens? You'll just have to read this previous post to find out.

Reference

Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency viagra cialis online pharmacy pharmacy. 2011 - in press. PMID: 21256625


.

And The Answer Is ...

Not much time citrate generic online pharmacy viagra post today, so I'll quickly give you the answer to yesterday's tornado trivia question ... which was: what is the return period in years for a
...

Britain is a country whose old men are living longer and longer and in terms of longevity, are catching up with its women

See also: cheap cialis | 




According to research, life expectancy for men is rapidly catching up with women. The gap in longevity between the sexes has narrowed almost 12 months over the past decade and now stands at 4.2 years, although men in some parts of London, Lincolnshire and Kent have closed the difference by 3 times the national average.

Nick Flint, the Chief Executive of 'Club Vita', a consultancy to the pensions industry, said :
" Men are indeed catching up with women. The decline of smoking has played a big part in this, but so has the increase in gym membership, corporate heath check-ups and men's' fitness magazines. Even the advent of order cialis has been important.....the drug has encourages men to go to see their doctor. Once there, other problems can be picked up."

P.S. My 'smile/laughter tonic' for the day is entitled 'Viagra Works' :

Nonagenerian Viagra

A 90 year old man marries a 20 year old woman, and so goes to his doctor for viagra. The doctor says, "Sorry but giving generic cialis to a 90 year old can be dangerous."

The old man begs and pleads for Viagra, and eventually the doctor gives in. He stresses though that it can only be taken under strict guidelines and only for seven days. The doctor says, "Take half a dose one day then skip the next day, then take another half-dose then skip the next day, and so on until the seventh day".

The old man does as he's instructed the following week after which his wife phones the doctor and says "He's dead!"

The doctor said, "I knew if I gave him Viagra it would kill him." The young widow said, "No, it wasn't the Viagra that killed him, it was all that damned skipping".