Low Dose Ketamine Intra Nasal Traumatology
Low Dose Ketamine Intra Nasal Traumatology
To evaluate the efficacy and safety of early administration of low-dose intranasal ketamine
 analgesic agents in patients with moderate to severe pain in the ED in reducing the need for
 opioid or non opioids analgesic agents.
Intranasal ketamine for treatment of acute pain in the emergency department : A randomized
 controlled trial

 Introduction :

 Pain is the most common complaint for emergency department (ED) visits [1].The provision of
 adequate, safe, and timely analgesia is a core component of patient care in the emergency
 department (ED). Ketamine is a noncompetitive Nmethyl- D-aspartate and glutamate receptor
 antagonist that decreases central sensitization, "wind-up" phenomena, and pain memory [2,3].

 At subdissociative doses (0.1 to 0.6 mg/kg; most commonly 0.3 mg/kg) maintains potent
 analgesic and amnestic effects that are accompanied by preservation of protective airway
 reflexes, spontaneous respiration, and cardiopulmonary stability [4-6].

 Intranasal route ….

 Objective of the study :

 To evaluate the efficacy and safety of early administration of low-dose intranasal ketamine
 analgesic agents in patients with moderate to severe pain in the ED in reducing the need for
 opioid or class III analgesic agents.

 Materials and Methods :

 Study design :

 It is a ramdomized, prospective, double blind, controlled, multicentric trial. The study is
 registered with clinical.tria.gov (…….).

 Study Setting and Selection of Participants :

 The trial is conducted in three community teaching hospitals :

 -  Emergency department, fattouma bourguiba university hospital, monastir, tunisia

 -  Emergency department, sahloul university hospital, sousse, tunisia

 -  Emergency department, farhat hached university hospital, sousse, tunisia

 ED principal investigators maintain the randomization list, which is generated before the
 start of the study, prepare the medication, and deliver it to the treating physician in a
 blinded manner.

 Inclusion criteria :

 The study includes patients aged 18 to 80 years who presented to the ED with acute limb
 trauma pain with a visual analogue scale (VAS) of 5 or more on a standard 11- point (0 to
 10). An informed consent is necessary.

 Exclusion criteria :

 -  Pregnancy,

 -  Breast-feeding,

 -  Altered mental status,

 -  Allergy to ketamine or morphine or

 -  Weight less than 46 kg or greater than 115 kg,

 -  Unstable vital signs (systolic blood pressure <90 or >180 mm Hg, pulse rate <50 or >150
 beats/min, and respiration rate <10 or >30 breaths/min),

 -  Medical history of acute head or eye injury, seizure, intracranial hypertension, chronic
 pain, severre renal or hepatic insufficiency,

 -  Alcohol or drug abuse,

 -  Psychiatric illness,

 -  Recent (4 hours before) analgesic agent use.

 Protocol :

 In the triage area, each patient having the inclusion criteria receives 25mg of ketamine in
 0.5 ml of serum saline in one pulverisation per nostril or 0.5 mL of normal saline solution
 in one pulverisation per nostril as a placebo according to the predetermined randomization
 list. None of the treating physician or nurses is aware about the medication received. In all
 patients included, the investigators collect vital signs ; demographic and clinical data.

 Study investigators record VAS, and adverse effects at 15, 30, 60, 90, and 120 minutes.

 At 30 minutes, if patients report a pain numeric rating scale score of 5 or greater and
 request additional pain relief, titrated morphine is administered as a rescue analgesic with
 a dose of 0.1 mg/Kg repeated every 3 to 5 minutes if the pain numeric rating scale score is
 still greater or equal to 3.

 All data recorded on data collection sheets, including sex, demographics, medical history,
 and vital signs, were entered into SPSS (version 20.0; IBM Corp) by the research manager.

 Patients's informed consent is obtained. The ethic commitee of our institution approved the
 study.

 Endpoints :

 Primary endpoints :

 - Need for rescue opioids during ED stay

 Secondary endpoints :

 -  requirement of non-opioids analgesic agents.

 -  percentage of patients discharged from the ED with VAS <30.

 -  Safety : adverse events
Inclusion Criteria:

 -  The study includes patients aged 18 to 80 years who presented to the ED with acute
 limb trauma pain with a visual analgesic scale (VAS) of 5 or more on a standard 11-
 point (0 to 10). An informed consent is necessary.

 Exclusion Criteria:

 -  - Pregnancy,

 -  Breast-feeding,

 -  Altered mental status,

 -  Allergy to ketamine or morphine or

 -  Weight less than 46 kg or greater than 115 kg,

 -  Unstable vital signs (systolic blood pressure <90 or >180 mm Hg, pulse rate <50 or
 >150 beats/min, and respiration rate <10 or >30 breaths/min),

 -  Medical history of acute head or eye injury, seizure, intracranial hypertension,
 chronic pain, severre renal or hepatic insufficiency,

 -  Alcohol or drug abuse,

 -  Psychiatric illness,

 -  Recent (4 hours before) analgesic agent use.