EXPLANATION OF CLINICAL PRACTICE GUIDELINE CONTENT

EXPLANATION OF CLINICAL PRACTICE
GUIDELINE CONTENT
The updated clinical practice guideline is shown in Figure 1,
with major changes from the previous version summarized in
Figure 2. The following is explanatory information and
evidence in support of its sequential elements. A general
approach to ketamine dissociative sedation is shown in Figure 3.
Objective
To provide evidence-based recommendations for use of
ketamine dissociative sedation in the ED.
Definition of Dissociative Sedation
This recommended7,10 definition has been crafted according
to the unique features of the dissociative state.4,12,15-17
Characteristics of the Ketamine “Dissociative State”
Detailed descriptions of the unique clinical manifestations of
ketamine are beyond the scope of this guideline, and interested
readers are referred to other sources.4,12,15,16,23
Indications
The literature is strongly supportive of the safety and efficacy
of ED dissociative sedation for a variety of brief painful or
emotionally disturbing procedures in both children2,3 and
adults,24-28 eg, fracture reduction, laceration repair, abscess
drainage. Dissociative sedation is useful for procedures in the
mentally disabled, who are often uncooperative.29,30
Ketamine may also be safely used for longer procedures,
2-4,12,15,16 although patients in whom prolonged
intervention is anticipated may be more optimally treated
with other agents or in other settings. For procedures that
require motionless sedation, such as computed tomography or
magnetic resonance imaging, ketamine is less effective because
of occasional random movements typical of dissociative
sedation, which may result in poor-quality radiographic study
results.11,23 Ketamine offers no advantage over pure sedativehypnotics
in this setting.

Contraindications: Absolute (Risks Essentially Always
Outweigh Benefits)
Age. There are multiple anecdotal observations and reported
cases of airway complications with ketamine in infants younger
than 3 months, including airway obstruction, laryngospasm,
and apnea.4,12,16,31,32 This propensity toward airway adverse
events is not particular to ketamine but rather represents infantspecific
differences in airway anatomy and reactivity and
laryngeal excitability.4,12,16,33