ERcast: Clinical Perspectives Podcast Preview
The summary below is from an episode of ERcast: Clinical Perspectives
Nebulized ketamine appears to provide clinically meaningful short-term analgesia for acute painful conditions in the emergency department. In a randomized ED trial, a 0.75 mg/kg dose delivered through a breath-actuated nebulizer was effective and well tolerated, with a possible signal for fewer psycho-perceptual effects than IV subdissociative ketamine.
Nebulized Ketamine for ED Analgesia
- Breath-actuated delivery route: Ketamine was given through a breath-actuated nebulizer, offering a needle-free analgesic route for acute ED pain when IV access is delayed, undesirable, or part of the practical question.
- Headline effective dose: A 0.75 mg/kg nebulized dose was both efficacious and safe, making the lowest studied regimen the practical takeaway rather than escalating automatically to higher doses.
- Pain score response: Mean pain scores fell by about 4 points from baseline, and the reduction was clinically significant by 30 minutes across all three dosing regimens.
- No higher-dose advantage: The 1.0 mg/kg and 1.5 mg/kg regimens did not outperform 0.75 mg/kg at 30 minutes, arguing against a clear analgesic payoff from simply increasing the dose.
- Psycho-perceptual effect signal: Psycho-perceptual effects occurred in about 25% of patients, a lower rate than prior IV subdissociative ketamine reports, though cross-trial comparisons need caution. We get into the route-comparison nuance in the episode.
- Rescue opioid requirement: Only 10 of 120 patients needed opioid rescue analgesia, a reassuring signal that nebulized ketamine may reduce escalation in selected ED pain presentations.
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References:
1.) Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017. PMID: 28283340
2.) Motov S et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A randomized Controlled Trial. Ann Emerg Med 2015. PMID: 25817884
Faculty
- Matthew DeLaney, MD, FACEP, FAAEM
Dr. Matthew DeLaney is an emergency medicine physician and educator based in Birmingham, Alabama. A native of Mobile, he earned his medical degree from the University of South Alabama and completed his emergency medicine residency at Maine Medical Center.Dr. DeLaney has experience in both community and academic emergency medicine and is known for his commitment to teaching and medical education. He lives in Birmingham with his wife, Erin, who is also a physician, and their two daughters.
- Salim Rezaie, MD
