Ketamine RSI for head injury

Reviewed and revised 11 December 2015; originally inspired by a talk by Mike Winters at Essentials 2010

OVERVIEW

• Traditionally ketamine was contra-indicated for use in rapid sequence intubation of the head injured patient
• This view has since been debunked
• Recent evidence suggests that ketamine may actually be useful in this setting

TRADITIONAL CONCERNS

Ketamine was traditionally “contraindicated” in patients with traumatic brain injury due to concerns about ketamine causing raised intracranial pressure:

• Mostly derived from studies performed in the 1970s
• Studies done on patients with non-traumatic intracranial lesions
• Changes in ICP measured as changes in CSF pressure at lumbar spine and lateral ventricles with extrapolation to changes in CBF
• Ketamine was shown to have deleterious increase in ICP predominantly in patients with obstructed CSF pathways

RECENT EVIDENCE

Human studies

• sub-anesthetic doses shown to produce small increases in CBF in healthy volunteers

Indirect studies (used as infusion post-intubation):

• Kolenda et al (1996)
  — ketamine/midazolam vs. fentanyl/midazolam in moderate to severe head injury – slightly higher ICP and CPP in ketamine group with no difference in outcome
• Albanese et al (1997)
  — propofol sedated ventilated patients with TBI – ketamine produced a decrease in ICP with no change in CPP
• Bourgoin et al (2003)
  — ketamine/midazolam vs. sulfentanyl/midazolam for moderate to severe TBI – no difference in mean daily ICP or CPP
• Bar-Joseph et al (2009)
  — sedated children with intracranial hypertension randomised to ketamine bolus — ketamine bolus decreased ICP and increased CPP

Animal studies:

• Ketamine may cause NMDA-mediated neurotoxicity in the developing brain, but no evidence in humans
• Does not appear to interfere with cerebral metabolism; does not increase cerebral oxygen consumption or reduce regional glucose metabolism

BOTTOM LINE

• The evidence that ketamine elevates ICP is weak
• There is no evidence that ketamine causes harm in TBI
• Ketamine’s haemodynamic stability may be of benefit in the patient with traumatic brain injury requiring rapid sequence intubation

References and Links

Journal articles

• Albanèse J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology. 1997 Dec;87(6):1328-34. PMID: 9416717.
• Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009 Jul;4(1):40-6. PMID: 19569909.
• Bourgoin A, Albanèse J, Wereszczynski N, Charbit M, Vialet R, Martin C. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003 Mar;31(3):711-7. PMID: 12626974.
• Domino EF. Taming the ketamine tiger. 1965. Anesthesiology. 2010 Sep;113(3):678-84. PMID: 20693870
• Green SM, Coté CJ. Ketamine and neurotoxicity: clinical perspectives and implications for emergency medicine. Ann Emerg Med. 2009 Aug;54(2):181-90. PMID: 18990467.
• Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011 Dec;28(12):1076-7. PMID: 22101599.
• Kolenda H, Gremmelt A, Rading S, Braun U, Markakis E. Ketamine for analgosedative therapy in intensive care treatment of head-injured patients. Acta Neurochir (Wien). 1996;138(10):1193-9. Erratum in: Acta Neurochir (Wien) 1997;139(12):1193. PMID: 8955439.
• Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006 Feb;18(1):37-44. PMID: 16454773