Saturday, July 26, 2008

Ketamine Harshing My Mellow

I've given ketamine to several pint sized humans in my old ER with predictable results: the eyes get glassy and go in opposite directions, the doc performs whatever needs to be done, kid cries a little, parent freaks out because the child does not look sedated, procedure is over, kid starts coming around, and then kid freaks out.

Previously I gave little pause to this common chain of events but tonight seeing an adult go through the hellish journey of a bad ketamine dose I am starting to rethink our cavalier usage of it with the tots.

38 year old man comes in with anterior dislocation of his shoulder. He injured it last week and then tonight while asleep it popped out again. He was in excruciating pain and had to keep his elbow suspended above his head for comfort (something I have never seen). Anyway as we wait for the pre-reduction films to come back my colleague pops 50mg of ketamine into the man's IV and we wait for him to get all gooey so we can begin the reduction.

As simple as slowly lowering the arm allows the shoulder to slide back into position. Nice and smooth. And the reduction is complete.

Then he starts losing it.

The man is crying out in complete horror and fear, waking up our few sleeping inpatients. "What is happening to that guy?" is muttered throughout the department. He was shrieking like he was at hells gate, tears streaming down his face, a look of complete panic in his glassy eyes. Mostly nonsense peppered with "noooooo!" , "don't let me go under again!!!" and "what have you done to me?" were some of the phrases that began to ring through the hallways of our previously peaceful 5am ER department.

I took up full time occupancy at the bedside trying to calm him down and reassure him. He thought that each time the BP cuff inflated that I was putting him under again. Then he was sure that because I kept telling him where he was and that we had just fixed his shoulder that he was in some sort of loop of existence that he couldn't get out of.

Finally he started to come around a bit but was still very leery of his surroundings and my motivations with regard to his well being. I asked him simple and direct questions about his life and family to keep him on track, at his insistence "ask me more questions". I myself was having flashbacks to talking friends down from bad trips at rainy music festivals and loud dingy clubs, "no Kent, there are no worms in your tent and no they are not crawling through the ground and then through you..."

He was finally able to focus on my face and told me that he had seen horrible things and for a while had been reliving a frightening experience from high school when he was bullied for being gay because he was the smallest guy in his class. My heart really went out to the guy. He was visibly rattled.

His wife and daughter showed up and their presence seemed to solidify that things were once again as they seemed. I knew he was OK when I heard him singing, "what a long strange trip it's been" while I drew up his dimenhydrinate for the road.

After he left I couldn't help but think of the many babies and toddlers I've seen coming out of ketamine anesthesia. All of them did seem to have an air of panic about them and most were carried out of the department clinging to a parent, wailing. I always just chalked it up to being scared, post-procedure, and being in a strange place. But now I wonder what 'long strange trips' they'd been on. What had their little Sesame Street watching brains created for them to trip on?

The other thing that gave me pause was, back in my raver days I remember many kids taking ketamine for parties. I'm usually not one to judge about the poisons people pick to party on but, ketamine?? Seriously? How much more dangerous can you get than being surrounded by thousands of strangers on a dissociative anesthetic which can cause you to slip into a coma? Really. Nothing says "party girl" like being in a vegetative state at a rave. Strange indeed.

A fascinating drug nonetheless. The wiki is an an interesting link ,if you've got time to give it a read.

My medical directive may have to be expanded from "DNR----and if you have to restrain me please do it chemically and not physically" to also include "and if I need to be consciously sedated please do it with midazolam and fentanyl. Thank you."

Note 'ketone' and 'amine group' in structure, hence the name. Sorry, I love organic chemistry. I had to!


Rogue Medic said...

I agree that we do not know what the kids are experiencing. This may be similar to the old "kids don't feel pain, so they don't need analgesia," BS we used to hear. Or, it may be a difference between the processing of stimuli by a pediatric brain as opposed to an adult brain.

The research on medication to control the emergence reactions has not been productive, but I haven't seen anything on it in a while. The last I remember was something showing that midazolam did nothing to ease the emergence reactions.

Adults have reported the near death experience reaction when taking ketamine. The going to the light and other things reported by resuscitated people. Many seem to have a life changing experience after taking this. Some people report living more altruistic lives after taking ketamine.

I never have taken any dissociative anesthetic, but if I need to be sedated, ketamine is definitely my first choice. Although I think I would insist on being fully restrained prior to coming out of it, just in case. A person on a dissociative anesthetic with an attitude can be very dangerous. Not that I think I would have any problems, but it is a reasonable precaution.

Albinoblackbear said...

I have heard of the "near death" as well, and I believe the wiki talks about patients reporting seeing the gates of hell. Not what I would want to be trippin'on while having a procedure done to me. No thanks.

I know GA is baaaadddd. But when I awoke from my quad wisdom tooth extraction I was in my happy place and inquiring to the nurse when they were going to take my teeth out as she pulled the yard lengths of bloody gauze from my mouth. I'd sign up for that again tomorrow!!