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KETAMINEMechanism of Action:Ketamine is a dissociative anesthetic that is structurally similar to phencyclidine (PCP), which interrupts the connection between the thalamo-neocortical tracts and the limbic system. In addition, it stimulates many different receptors, including the opioid and catecholamine receptors. It is unique among sedative agents in that it also provides analgesia in addition to the amnestic and sedative effects. The sympathomimetic effects cause an increase in heart rate, blood pressure, and cardiac output. It is also a bronchodilator, and thus may be beneficial in patients with bronchospasm requiring intubation.Indications:Induction agent for rapid sequence intubation (RSI). This is now an alternative option to etomidate.Chemical stabilization of excited delirium (see separate protocol).Pain management (currently only for emergency use when opioids are unavailable).Precautions:Increased blood pressure due to catecholamine release. Use with caution in patients with markedly elevated blood pressures (>200 systolic).Reemergence phenomenon. As with all intubated patients, continued sedation must be provided before the induction agent has worn off. Benzodiazepines will generally mitigate any agitation.Increased ICP has been a theoretical concern, however studies have not shown a significant increase in ICP with the use of ketamine. Therefore, ketamine may still be considered in patients who may have increased ICP, such as trauma patients. However, if severe hypertension is also present, ketamine may be best avoided.Respiratory arrest. Rapid IV push of ketamine will often cause respiratory arrest. Give IV doses over 1-2 minutes and always be prepared to manage the airway when using ketamine.It is wise to avoid the dosing range of 0.5 mg/kg to 1 mg/kg, since these dosages may cause psychosis and agitation. Even doses of only 0.4 mg/kg can cause troubling behavioral changes, which can compromise patient care.Drug Interactions:Many drugs may affect the metabolism of ketamine, however there are no drugs with which the addition of ketamine would be contraindicated.Administration:Induction agent: 1-2 mg/kg IV Excited Delirium: 2-4 mg/kg IM, 1-2 mg/kg IVAnalgesia: 0.2 mg/kg IV, one-time dose Special Notes:Onset of action is about 30-60 seconds IV and 3-5 minutes IM.Duration of action is about 10-15 minutes IV and 15-25 minutes IM.When using as an induction agent and elevated ICP is suspected, consider using a lower dose along with midazolam.Avoid in patients with severely elevated blood pressure, unless the blood pressure elevation is due to a readily reversible cause, such as pain or flash pulmonary edema. ................
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