Written by Hunter Perala and Ketan Patel
Spoon Feed
Prehospital intranasal ketamine, in addition to fentanyl, did not provide additional analgesic benefit beyond fentanyl alone, but was safe with no significant side effects.
Death to the K-hole?
This study is important to emergency medicine providers, especially those managing EMS systems, because it evaluates the efficacy and safety of adding intranasal ketamine to fentanyl for prehospital trauma pain management. Utilizing a single EMS system, pre-hospital male patients with acute trauma and a pain score ≥ 7 were given a randomized dose of either placebo or 50mg of ketamine intranasal in addition to their dose of fentanyl. EMS providers were blinded to the administration of this dose. The study found that adding 50 mg of intranasal ketamine to fentanyl in prehospital trauma care did not significantly improve pain reduction compared to fentanyl alone, with 44.7% of the ketamine group and 36% of the placebo group reporting at least a 2-point pain reduction that was not statistically significant. It did not cause any significant adverse affects. The authors noted that the study may have simply been underpowered to detect this difference. Due to unknown pregnancy status, females were excluded from the study, limiting its global applicability. Shortly after completion of this trial, Trauma Combat Casualty Care practices increased the fixed dose to 100mg of ketamine intranasal, suggesting that perhaps dosages studied here were inadequate for proper pain control.
How will this change my practice?
Studies like this highlight the gap in high-quality research assessing novel methods of pain control, especially when access issues are a concern, as in the EMS and trauma settings. However, I believe future research will continue to assess the true effects and benefits of these approaches. For me, this article does not shelve ketamine in my acute pain practice, and I will continue to utilize it in its many forms and administration modalities, while also regularly assessing patients for clinical and adverse affects.
Source
Out-of-Hospital Intranasal Ketamine as an Adjunct to Fentanyl for the Treatment of Acute Traumatic Pain: A Randomized Clinical Trial. Ann Emerg Med. 2024 Oct;84(4):363-373. doi: 10.1016/j.annemergmed.2024.04.018. Epub 2024 Jun 12. PMID: 38864781
