Ketamine-induced Changes in Blood Pressure and Heart Rate in Pre-hospital Intubated Patients

  • Milan Kirit Sheth Eastern Mennonite University, Harrisonburg, VA 22802, USA
  • Asher Brand PHI Air Medical, Arizona, USA
  • Julia Halterman Eastern Mennonite University, Harrisonburg, VA 22802, USA

Abstract

When a patient experiences trauma, pre-hospital rapid sequence intubation (RSI) is often the course of action. While RSI is associated with favorable neurological outcomes among traumatic brain injury patients, it also carries the risk of increased hypotension and bradycardia. Ketamine is a fast-acting anesthetic agent used in RSI, attractive due to its ability to raise heart rate (HR) and blood pressure (BP) and thus potentially lessening the severity of RSI-related hypotension and bradycardia. However, research in support of its use is inconclusive, with different studies reporting increases or decreases in BP and HR after ketamine administration. To study the effect of ketamine on HR and BP during RSI, we analyzed the data obtained from 1,516 patients who received trauma and non-trauma medical care including RSI from first responders and emergency personnel using two different statistical methods. We determined if there was any association between the vital signs prior to administration of ketamine and outcomes such as bradycardia and/or hypotension post-ketamine administration in patients undergoing RSI. We found that the vital signs prior to administration of ketamine (i.e. BP and HR) predict the development of bradycardia and/or hypotension in patients undergoing RSI and the relationship between baseline vital signs and the development of bradycardia and/or hypotension is moderated by the dose of ketamine. Results obtained from this study may help responders and emergency care personnel to identify the patients that are likely to benefit from ketamine as an anesthetic agent.

Keywords: Ketamine, Blood Pressure, Heart Rate, Hypotension, Bradycardia, Rapid Sequence Intubation

Downloads

Download data is not yet available.

Author Biographies

Milan Kirit Sheth, Eastern Mennonite University, Harrisonburg, VA 22802, USA

Second-year student of M.A. (Master of Arts in Biomedicine) for the academic year 2016/17 in the Department of Biology and Biomedicine

Asher Brand, PHI Air Medical, Arizona, USA

Emergency Medicine Physician

Julia Halterman, Eastern Mennonite University, Harrisonburg, VA 22802, USA

Assistant Professor of Biology and Director of Masters of Arts in Biomedicine Program, Department of Biology and Biomedicine

References

[1]        AR Nakstad, HJ Heimdal, T Strand, M Sandberg."Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service," Am J Emerg Med, vol. 29, no.6, p. 639-44, 2011.


[2]        SA Bernard, V Nguyen, P Cameron, K Masci, M Fitzgerald, DJ Cooper, T Walker, Std BP, P Myles, L Murray et al. "Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial," Ann Surg, vol. 252, no. 6, p. 959-65, 2010.


[3]        A Timmermann, C Eich, SG Russo, U Natge, A Brauer, WH Rosenblatt, U Braun. "Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians," Resuscitation, vol. 70, no.2, p. 179-85, 2006.


[4]        M Eckstein, L Chan, A Schneir, R Palmer. "Effect of prehospital advanced life support on outcomes of major trauma patients," J Trauma, vol. 48, no.4, p.643-8, 2000.


[5]        B Burns, K Habig, H Eason, S Ware. "Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service," Air Medical Journal, vol. 35, no.1, p.28-32, 2015.


[6]        MT Cudnik, CD Newgard, M Daya, J Jui. "The impact of rapid sequence intubation on trauma patient mortality in attempted prehospital intubation," J Emerg Med, vol. 38, no.2, p. 175-81, 2010.


[7]        ZB Perkins, M Gunning, J Crilly, D Lockey, B O'Brien. "The haemodynamic response to pre-hospital RSI in injured patients," Injury, vol. 44, no.5, p. 618-23, 2013.


[8]        HE Wang, DP Davis, MA Wayne, T Delbridge. "Prehospital rapid-sequence intubation--what does the evidence show? Proceedings from the 2004 National Association of EMS Physicians annual meeting," Prehosp Emerg Care, vol. 8, no.4, p. 366-77, 2004.


[9]        RS Sehdev, DA Symmons, K Kindl. "Ketamine for rapid sequence induction in patients with head injury in the emergency department," Emerg Med Australas, vol. 18, no.1, p.37-44, 2006.


[10]      SJ Mercer. "The drug of war-a historical review of the use of ketamine in military conflicts," J Royal Naval Medical Serv., vol. 95, no.3, p. 145-150, 2009.


[11]     JD Tobias, M Leder. "Procedural sedation: A review of sedative agents, monitoring, and management of complications," Saudi J Anaesth, vol. 5, no.4, p. 395-410, 2011.


[12]      K Porter. "Ketamine in prehospital care," Emerg Med J, vol. 21, no.3,  p. 351-4, 2004.


[13]      D Scherzer, M Leder, JD Tobias. "Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients," J Pediatr Pharmacol Ther, vol. 17, no.2, p.142-9, 2012.


[14]      V Ayatollahi, S Behdad, S Kargar, T Yavari. "Comparison of effects of ephedrine, lidocaine and ketamine with placebo on injection pain, hypotension and bradycardia due to propofol injection: a randomized placebo controlled clinical trial," Acta Med Iran, vol. 50, no. 9, p. 609-14, 2012.


[15]      S Rajan, A Hassain, N Puthenveettil, L Kumar. "Efficacy and safety of low-dose ketamine as an adjunct analgesic and amnesic during caesarean section under general anaesthesia," Indian J Anaesth, vol. 59, no.10, p. 653-7, 2015.


[16]      FK Özkan, Ziya; Süren, Mustafa. "The effect of intravenous ketamine on prevention of hypotension during spinal anesthesia in patients with benign prostatic hyperplasia," Nobel Medicus Journal, vol. 7, no. 3, p.82, 2011.


[17]      JY Kim, JS Lee, HY Park, YB Kim, Y Kwon, HJ Kwak. "The effect of alfentanil versus ketamine on the intubation condition and hemodynamics with low-dose rocuronium in children," J Anesth, vol. 27, no.1, p. 7-11, 2013.


[18]      J Barois, P Tourneux. "Ketamine and atropine decrease pain for preterm newborn tracheal intubation in the delivery room: an observational pilot study," Acta Paediatr, vol. 102, no. 12, p. e534-8, 2013.


[19]      R Abbasivash, MM Aghdashi, B Sinaei, F Kheradmand. "The effects of propofol-midazolam-ketamine co-induction on hemodynamic changes and catecholamine response," J Clin Anesth, vol. 26, no. 8, p. 628-33, 2014.


[20]      OK Losvik, MK Murad, E Skjerve, H Husum. "Ketamine for prehospital trauma analgesia in a low-resource rural trauma system: a retrospective comparative study of ketamine and opioid analgesia in a ten-year cohort in Iraq. Scand," J Trauma Resusc Emerg Med, vol. 23, p.94, 2015.


[21]     KP Tran, Q Nguyen, XN Truong, V Le, VP Le, N Mai, H Husum, OK Losvik. "A comparison of ketamine and morphine analgesia in prehospital trauma care: a cluster randomized clinical trial in rural Quang Tri province, Vietnam.," Prehosp Emerg Care, vol. 18, no.2, p. 257-64, 2014.


[22]      MY Rady, HA Smithline, H Blake, R Nowak, E Rivers. "A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department," Ann Emerg Med, vol. 24, no.4, p. 685-90, 1994.


[23]      SM Green, MG Roback, RM Kennedy, B Krauss."Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update," Ann Emerg Med, vol. 57, no.5, p. 449-61, 2011.


[24]      SM Green, N Kuppermann, SG Rothrock, CB Hummel, M Ho. "Predictors of adverse events with intramuscular ketamine sedation in children," Ann Emerg Med, vol. 35, no.1, p.35-42, 2000.


[25]      SM Green, MG Roback, B Krauss, L Brown, RG McGlone, D Agrawal,  M McKee, M Weiss, RD Pitetti, MA Hostetler et al. "Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children," Annals of Emergency Medicine, vol.5, no. 2, p. 158-168, e4, 2009.


[26]      B Price, AO Arthur, M Brunko, P Frantz, JO Dickson, T Judge, SH Thomas. "Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting," Am J Emerg Med, vol. 31, no.7, p. 1124-32, 2013.


[27]     A Sibley, M Mackenzie, J Bawden, D Anstett, C Villa-Roel, BH Rowe. "A prospective review of the use of ketamine to facilitate endotracheal intubation in the helicopter emergency medical services (HEMS) setting," Emerg Med J, vol. 28, no.6, p. 521-5, 2011.


[28]      SL Ballow, KL Kaups, S Anderson, M Chang. "A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients," Journal of Trauma and Acute Care Surgery, vol. 73, no.6, p. 1401-1405, 2012.


[29]      M Miller, N Kruit, C Heldreich, S Ware, K Habig, C Reid, B Burns. "Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index," Ann Emerg Med, vol. 68, no.2, p.181-188 e2, 2016.


[30]      KF Montoya, JD Charry, JS Calle-Toro, LR Núñez, G Poveda."Shock index as a mortality predictor in patients with acute polytrauma," Journal of Acute Disease, vol. 4, no. 3, p. 202-204, 2015.


[31]      V Pandit, P Rhee, A Hashmi, N Kulvatunyou, A Tang, M Khalil, T O'Keeffe, D Green, RS Friese, B Joseph. "Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank," J Trauma Acute Care Surg, vol. 76, no.4, p. 1111-5, 2014.


[32]      WA Tweed, M Minuck, D Mymin. "Circulatory responses to ketamine anesthesia," Anesthesiology, vol. 37, no.6, p. 613-9, 1972.


[33]      PF White, WL Way, AJ Trevor. "Ketamine--its pharmacology and therapeutic uses," Anesthesiology,  vol. 56, no.2, p. 119-36, 1982.


[34]      DA Schwartz, LD Horwitz. "Effects of ketamine on left ventricular performance," Journal of Pharmacology and Experimental Therapeutics, vol. 194, no.2, p. 410-414, 1975.


 [35]     DL Traber, RD Wilson RD, LL Priano. "Differentiation of the Cardiovascular Effects of CI-581," Anesthesia & Analgesia, vol. 47, no.6, p. 769-778, 1968.

Published
2017-10-04
Section
Graduate Research Articles
How to Cite
[1]
M. Sheth, A. Brand, and J. Halterman, “Ketamine-induced Changes in Blood Pressure and Heart Rate in Pre-hospital Intubated Patients”, Advanced Journal of Graduate Research, vol. 3, no. 1, pp. 20-33, Oct. 2017.