So, there's effective. And then there's effective, but insane. I am aware that low-dose continuous infusions of ketamine are excellent adjunctive therapies to decrease narcotic use in trauma and orthopedic patients, but I have never seen ketamine used in bolus form to treat acute pain in the out-of-hospital setting.
But, that's what we have. After an initial 5mg IV bolus of morphine, patients were randomized to receive either additional morphine or ketamine boluses - 1 to 5mg of morphine every five minutes, or 10 to 20mg of ketamine every three minutes. Pain medication was given per protocol until relief or adverse events. And, the ketamine group was superior - pain scores dropped 5.6 points on the numerical verbal scale with ketamine and 3.2 with morphine.
However, the ketamine group also had a 39% incidence of adverse effects, compared with 14% of the morphine group. The morphine group had mostly nausea, with one patient exhibiting a change in level of consciousness. However, the ketamine group had multiple patients with decreased consciousness, disorientation, and emergence phenomena. So, while the editor capsule summary states "Supplementing out-of-hospital opiods with low-dose ketamine is an effective strategy to mitigate trauma pain" he is technically correct, but the insanity of this strategy is trying to make an evidence-based decision about intracranial imaging after iatrogenically altering your patients prehospital.
What I appreciate best about this paper is how aggressive the paramedics were with treating pain - the patients receiving morphine averaged 14.4mg, with a standard deviation of 9.4mg! I see my residents ordering 2mg at a time and it drives me nuts.
"Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial"