Pediatric Pain Control in EMS Is Ketamine the Next Big Thing?

Pre-hospital pain control is moving at a rapid pace; it’s time to buckle up for an interesting ride. While Morphine is being laid to rest by many EMS agencies due to its side effect profile, time to peak effect and the inability to be administered intranasally, other medications are moving to the forefront of care. Ask any field provider about morphine and you are not likely to get a positive response. A typical call requiring morphine administration results in a very slow effect (25 minute peak), often leaving the paramedic in a precarious position. Patients remain in absolute agony, as they are being moved and transported to the local hospital. Then right as the transfer of care occurs and the doctor walks in the room the patient finally starts feeling better….and then gives the doctor all the credit. It’s these types of failures that have led EMS agencies to look for a better alternative.

The past few years has seen Fentanyl take a more prominent role in pre-hospital pain control. After all, it is the perfect EMS drug for pain for the same reasons that Midazolam (Versed) is for seizures. Fentanyl and Midazolam both have a very short onset of action. Lipid soluble Fentanyl rapidly crosses the blood brain barrier and leads to rapid clinical benefit. The 2010 paper by Saunders and Adelgais concluded that an intranasal Fentanyl dose of 2 mcg/kg provided effective analgesia for pediatric ED patients with painful orthopedic trauma within 10 minutes of administration. Contrast this with Morphine, the least lipid soluble narcotic available, which peaks 25 minutes after administration. What’s nice about Fentanyl’s rapid onset is that the field provider can address their patient’s pain prior to transport and feel confident that the issue has been addressed appropriately. It’s a win-win scenario and the “fast-on, fast-off” property makes Fentanyl the perfect EMS narcotic.

                                                                   Note the rapid peak to Fentanyl compared to Morphine

What are the downsides to Fentanyl? Perhaps more than any other narcotic, Fentanyl has a great potential for diversion. Many agencies that have experience with Fentanyl know this first hand and have taken extra precautions to prevent such activity. There is also the respiratory depression that comes along with Fentanyl. An inadvertent decimal point error and your patient (especially pediatric) will become apneic. Take for example a 1-year-old child with a femur fracture. This 10 kg child can receive a Fentanyl dose of 1 mcg/kg IV. That’s 10 mcg in total. What is the volume required for this dose? The drug comes packaged as 50 mcg/mL so the volume is 0.2 mL: a dose easily mistaken for 2 mL in a hurried scenario.  That's how the phrase “death by decimal point” was coined. On the flip side is the under-dosing of the very same drug. When used via the MAD device the dead space eats up 0.1 mL of the total volume. So when the 1-year old patient requires 0.2 mL, the MAD device takes half and leaves the child with the equivalent of a homeopathic dose. Lastly, let’s not forget the risk of "chest wall rigidity syndrome", thought mainly to be the result of rapid IV administration of Fentanyl. This anxiety-provoking clinical syndrome may be resistant to Naloxone while at the same time poorly responsive to BVM.  Succinylcholine may be the only answer, yet the field provider may not have access to this medication. Either way, it promises to be stressful irrespective of the provider’s level of airway experience.

While Fentanyl has left the station some time ago, another drug has emerged in adult care and is gaining rapid momentum. Ketamine Hydrochloride has become ‘all the rage’ among EM and retrieval physicians, so much so that one physician (Minh Le Cong) even made it his Twitter handle (@Ketaminh)….very clever! Ketamine has been used in the Pediatric Emergency Department safely, and frequently, for over a decade and a dose of 1 mg/kg slow IVP (at least one minute) is the go-to medication for most short, painful procedures in children. The benefits are clear and include maintenance of airway reflexes and no effect on respiratory rate, all while creating a rapid dissociative state. Furthermore, Ketamine is safely and easily administered IV, IM and IN (dosing recommendations differ based on route of administration).

                                                                                        Ketamine 500 mg/5 mL (Best for adults)

Downsides of Ketamine are few and include laryngospasm, more so when the drug is pushed rapidly IV. Unlike the rigid chest seen with Fentanyl, the laryngospasm seen with Ketamine can be reversed with skillful BVM and knowledge of “Larson’s Maneuver.” Succinylcholine may be required as a last resort, although this is very unlikely. Lastly, diversion of Ketamine is a significant problem and for years it was the most common reason for break-ins to Veterinarian’s offices. The diversion issue for this drug has spread to clinics and hospitals, and the concern is that EMS is the next obvious target.

                                                                                                      Larson’s Maneuver

EMS agencies, in the US and around the world, have added Ketamine for the acutely agitated patient (Excited Delirium Syndrome) with great success. North Memorial Ambulance Service & Aircare, in Minneapolis was one of the first agencies to do so and have since reported great success with its use in the field.  Their use of Ketamine for agitation, RSI, sedation and pain control is outlined very nicely here.  Palm Beach County Medical Director, Dr. Ken Scheppke, had similar early success in Florida and published his findings in 2014. Broward County Florida EMS agencies have recently ramped up use of Ketamine due to the sudden explosion of Flakka in the region. Episodes of hypoxia have been noted both anecdotally and in previous literature, more so when a benzodiazepine is added to prevent an emergence reaction. This is also likely a consequence of the poly-pharmacy commonly seen in the acutely agitated adult patient in the field.


                                               Florida Streaker High On 'Flakka' Said He'd 'Rather Die Than Be Caught' By Imaginary Pursuers

Ketamine For Pain
The new question now is “can Ketamine be used for pre-hospital pain control in adult and pediatric patients?” The answer is clear. Dating back to the early 90’s, studies have repeatedly demonstrated the benefit and safety profile of this once feared drug. In 1997, Humphries et al described the superiority of oral Ketamine over Acetaminophen-codeine plus Diphenhydramine in pediatric burn patients. Ketamine has been extremely successful in treating chronic pain conditions such as Reflex Sympathetic Dystrophy (RSD) and Sickle Cell Disease, specifically in the pediatric population. A comprehensive review of Ketamine use in the pediatric emergency setting was published in 2004 (Emerj Med Journal – full article). It evaluated 97 case series’ which included a total of 11,589 cases of Ketamine use in children. Only 2 cases total required intubation, but interestingly even children receiving up to 100 times the intended dose suffered no adverse events. Laryngospasm was described as “very rare” and having occurred at a greater rate with instrumentation of the oropharynx or hypo-pharynx. Finally the review reported emergence phenomena occurring in up to 10% of cases. The incidence was lower with children under 10 years of age, doses of 2 mg/kg or less (2% incidence), and when Ketamine was provided intramuscularly.

A growing number of EMS agencies have taken the lead and have begun using it in the field for pediatric pain management at a dose of 0.2 – 0.25 mg/kg. Polk County Fire Rescue in Florida, North Memorial in Minnesota and Rugby EMS in North Dakota have all added Ketamine to their repertoire with great success. Like Fentanyl, however, Ketamine volumes in pediatric patients are very small, specifically when using the 100 mg/mL concentration. The pain dose is only a fraction of the RSI/Sedation dose and therefore leads to even smaller volumes. This error prone item can be mitigated by carrying two different concentrations of Ketamine (pediatric and adult). I recommend that EMS agencies carry the 10 mg/mL concentration (image (c) below), making the volumes easier and safer to administer.
                                                                            
                                                                   a) 100 mg/mL (Adult)                       b) 50 mg/mL                    c) 10 mg/mL (Pediatric)

                                                                              Ketamine HCL is available in several concentrations

The image below illustrates how Polk County Fire Rescue, a large Florida EMS agency, which covers a population of approximately 634,000, customized their pediatric dosing. Using the e-Handtevy web portal, Dr. Paul Banerjee (Medical Director) and Richard Criss (Medical Training Officer) easily added Ketamine for both pain and sedation (note the significantly different doses). Both indications are safely used with the dilute form of Ketamine (10 mg/mL) described above (c). The image below is one page from the Polk County Fire Rescue Handtevy Medication Guide. The complete medication guide ranges from a 2 kg premature newborn up to a 60 kg pre-adolescent. 




It really is an exciting time in the pre-hospital arena with respect to pain control options for both adult and pediatric patients. Fentanyl has rapidly moved to the forefront in EMS, Ketamine appears to be staking its claim, and Morphine appears to be slowly fading from prominence. Both Fentanyl and Ketamine have their pros and cons but it is likely that Ketamine will leave a mark on the world of pre-hospital medicine for many years to come.

What is your agency's experience with Ketamine for pain pain control?  We'd love to hear about it as we strive continue to share best practices.

About Pediatric Emergency Standards, Inc.
Pediatric Emergency Standards Inc.was created to advance the quality of pediatric emergency medical care to all sick and injured children. With expertise in both pediatric emergency medicine and EMS, the company introduced an innovative product, the Handtevy™, which facilitates the rapid provision of critical drug doses to pediatric patients. Hospitals and EMS departments have embraced the Handtevy™, an award winning system that has the potential to significantly improve the care provided to critically ill children.

About Peter Antevy MD
Peter is an EMS medical director for Davie Fire Rescue, Coral Springs Fire Department, SW Ranches Fire Rescue and American Ambulance in Florida. He is the associate medical director for Palm Beach County Fire Rescue, Miramar Fire Rescue and Seminole Tribe Fire Rescue. Antevy serves as medical director at Coral Springs Fire Academy and Broward College’s EMS program and is a pediatric emergency medicine physician at Joe DiMaggio Children’s Hospital. He currently serves as the President of the Greater Broward EMS Medical Directors’ Association (GBEMDA) and is also the founder and chief medical officer of Pediatric Emergency Standards, Inc. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.