Ketamine in adult emergency medicine: controversies and recent advances.

OBJECTIVE To review the evidence for the use of ketamine in adult emergency medicine for procedural sedation and analgesia (PSA) and rapid sequence intubation (RSI), as well as to focus on the issues of recovery agitation, combination with propofol for PSA, and the use of ketamine as an induction agent in patients with acute head injury in need of definitive airway management. DATA SOURCES PubMed (1949-July 2011), EMBASE (1980-July 2011), Google Scholar (to July 2011), International Pharmaceutical Abstracts (1964-July 2011), and Cochrane databases were searched independently. A manual search of references was also performed. STUDY SELECTION English-language, full reports of experimental and observational studies evaluating ketamine in adults undergoing PSA and RSI in the emergency department (ED) were included if they reported efficacy or safety outcomes. DATA EXTRACTION Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. DATA SYNTHESIS Six studies that used ketamine for PSA were included. The majority reported adequate sedation with high patient satisfaction and lack of pain and procedural recall. There is no evidence to support the superiority of a combination of ketamine and propofol compared to propofol alone for PSA in adults. Recovery agitation is common but can be minimized with premedication with midazolam (number needed to treat 6). Two studies were identified that evaluated the role of ketamine for induction during RSI in the ED. Although ketamine is not a first-line agent for RSI, it is an alternative and may be used as an induction agent in patients requiring endotracheal intubation. CONCLUSIONS Ketamine is an effective agent in adults undergoing PSA and RSI in the ED. The best available evidence provides sufficient confidence to consider use of this agent in the ED.