After reading about the usage of Ketorolac (BMJ 2000;321:1247-51), a few
points came to mind and I know Rob Cocks is a list member:
1. There is no actual data about speed of onset, although the paper infers
that this is not a problem. In BNF it states that pain relief may not occur
for over 30 mins after iv or im injection!
2. For how many patients is 10mg of Ketorolac enough? If there is less
concern about side effects then a single dose would be simpler, rather than
having to titrate further amounts. Again dosage administration in the BNF
is different to that descibed in the paper.
3. Does it have all that much of an advantage over Diclofenac to offset its
cost? OK, ketorolac is less irritant im (being a smaller volume) & is
clearly easier to use iv (Diclofenac has to be as an infusion if given iv),
but I am not sure that these benefits would be enough to persuade our
Pharmacy & Drug Committee to swap over to it.
4. If it is effective, then iv Ketorolac/Midazolam sounds like a
potentially useful cocktail for reduction of shoulder dislocations, etc.
(Personally, just because patients may not remember it, I do not feel
midazolam alone is appropriate. Analgesia is necessary as well. Entonox
may be sufficient, but some form of analgesia is important on humanitarian
grounds and to help offset any potentially harmful physiological effects of
pain - tachycardias, dysrhythmias, etc.).
How many list members regularly use Ketorolac?
Regards,
Mike Dudley
Airedale
P.S. There seem to be an awful lot of Professors & Associate Professors in
HK !!
----- Original Message -----
From: RAY McGLONE <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, December 07, 2000 8:13 PM
Subject: Re: sedation in A&E: ketamine
> ----- Original Message -----
> From: Ray McGlone <[log in to unmask]>
> To: [log in to unmask] <[log in to unmask]>
> Sent: Thursday, December 07, 2000 5:32 PM
> Subject: Fw: Re: sedation in A&E: ketamine
>
>
> >
> > ----- Original Message -----
> > From: RAY McGLONE <[log in to unmask]>
> > To: The list will be of relevance to all trainees including
undergraduates
> > and <[log in to unmask]>
> > Sent: Wednesday, December 06, 2000 7:51 PM
> > Subject: Re: Re: sedation in A&E: ketamine
> >
> >
> > > We've been using Ketamine in Lancaster for over 5 years now. Since our
> > > original study I've continued collecting information. Using a dose of
2
> to
> > > 2.5 mg / kg IM with atropine we have done 369 Ketamine procedures with
> no
> > > incidence of laryngeal spasm. Once we get to 500 I'll publish the
> results.
> > > At this low dose you have to use local anaesthetic when suturing the
> > > children.
> > >
> > > It's safe so why aren't other departments using it in the UK?
> > >
> > > For manipulations one would have to use higher doses of ketamine.
> > >
> > > I use it when patients come to the A&E having been given Nubain by the
> > local
> > > Lancashire Paramedics. Supplemental doses of opiate often are not
> > effective.
> > > Usually 0.5 to 1 mg/kg ketamine iv is adequate. Fortunately Cumbria
> crews
> > > can give Diamorphine which they have been doing for over a decade now.
> > >
> > > Ray McGlone
> > > A&E Consultant
> > > Lancaster
> > > UK
> > > ----- Original Message -----
> > > From: P. Ransom <[log in to unmask]>
> > > To: <[log in to unmask]>
> > > Sent: Wednesday, December 06, 2000 1:09 AM
> > > Subject: Re: sedation in A&E: ketamine
> > >
> > >
> > > > At 03:36 PM 5/12/00 +0000, you wrote:
> > > >
> > > > Does anyone out there use ketamine ? Although included apparently
on
> > the
> > > > New Zealand hit list of "anaesthetic drugs" , it is in fact an
> > incredibly
> > > > safe drug, used all over the world with a vanishingly small number
of
> > > > serious complications, and allows manipulations, dressing changes
> etc
> > > to
> > > > proceed with total analgesia, and amnesia within 1 minute of
> > > > administration, while maintaining cardiac and respiratory function
> > > > intact. Scare stories of emergence phenomena are greatly
exaggerated.
> > I
> > > > usually have added a smidgen of midazolam just in case, though
trials
> > > have
> > > > shown that this is not necessary. You can't overdose on it, but
> > 0.5 -
> > > I
> > > > mg/kg slow IV injection always seems to do the trick, ( it can
> > > > occasionally apparently cause transient apnoea if IV pushed too
hard).
> > > > It does not to have muscle relaxant properties, but on the
occasions
> I
> > > > have used to for relocations ( on 2 hardened opiate + benzo-addicts
> > with
> > > > genuine dislocations ) it overcame muscle spasm well.
> > > > The main problems with it is that we don't use it enough. I don' t
> have
> > > > experience myself of using it with children, but all colleagues who
> do
> > > > prefer it to messing around with opiates or benzos.
> > > >
> > > > Paul Ransom
> > > > Perth,
> > > > Western Australia
> > > >
> > > >
> > > >
> > > > >Delighted with comments generated on the list re propofol sedation
in
> > > A&E.
> > > > >My literature search in FEb/March this year revealed only a case
> series
> > > report
> > > > >from the states of about 10 patients if I recall, Simon...sorry I
> dont
> > > have
> > > > >the reference to hand just now but if anyone is interested then you
> > know
> > > how
> > > > >to contact me!
> > > > >
> > > > >I agree with the general feeling that it is not the agent that is
the
> > > risk -
> > > > >it is the operator. Is it time for a policy statement from the
> faculty?
> > > > >Marten Howes
> > > > >SpR in A&E
> > > > >Blackpool
> > > >
> > >
> >
> >
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