Bedside Snapshot
- Use It For
- RSI induction (bronchospasm, hemodynamic fragility); procedural sedation; sub-dissociative IV or IN analgesia; severe agitation when safety is at risk
- Adult Dose
- RSI: 1–2 mg/kg IV/IO over 30–60 sec
- Pain: 0.25 mg/kg IV over 10–15 min (max 25 mg initial; 100 mg cumulative)
- Severe agitation: 3–5 mg/kg IM (low end) or 1 mg/kg IV
- Pediatric Dose
- Sedation: 1.5–2 mg/kg IV/IO (max 2 mg/kg) or 4–5 mg/kg IM; pain: 0.1–0.25 mg/kg IV (max 25 mg) or 1–1.5 mg/kg IN. No ketamine sedation <3 months; sedation generally avoided <6 months
- Onset / Duration
- IV: 30 sec / 5–10 min; IM: 3–4 min / 12–25 min; IN: 10–15 min / 30–60 min
- Do Not Give / Hold If
- BP rise would be dangerous (aortic dissection, active ischemia); hypersensitivity; no airway equipment or monitoring; schizophrenia or age <3 months for procedural sedation
- Watch For
- Laryngospasm (stridor, flat EtCO₂); apnea after fast push or with co-sedatives (SpO₂, EtCO₂); hypotension in catecholamine-depleted shock; emergence reactions
- Reversal / Rescue
- No reversal agent. Reposition, suction, BVM with O₂; laryngospasm: jaw thrust, PEEP, then paralyze and intubate; benzodiazepine for severe emergence
- Must Remember
- Three strengths (10, 50, 100 mg/mL): confirm concentration, mg and mL before drawing up, and dilute 100 mg/mL for IV. Base IM agitation doses on a conservative weight
Indications
Emergency & Prehospital
- Rapid sequence intubation induction: with bronchospasm or hemodynamic fragility (see RSI)
- Moderate to severe acute pain: sub-dissociative IV or IN dosing as an opioid alternative or opioid-sparing adjunct (off-label)
- Hyperactive delirium with severe agitation: when the safety of the patient, bystanders or staff is at immediate risk and de-escalation has failed (off-label)
- Field dissociation for painful procedures: entrapment, fracture or dislocation reduction where protocols allow
ED / ICU / Transport
- Procedural sedation and analgesia: reductions, burn care, pediatric laceration repair
- Analgosedation in ventilated adults: opioid-sparing adjunct, or sedative when hypotension limits propofol or dexmedetomidine (off-label; see analgosedation)
- Severe asthma needing intubation: induction agent of choice (bronchodilator); weak evidence as a non-intubated rescue (off-label, specialist)
- Super-refractory status epilepticus: NMDA-antagonist infusion under neurocritical care direction (off-label, specialist)
Other Uses
- General anesthesia: sole agent, induction or supplement (FDA-labeled)
- Treatment-resistant depression: off-label infusions; esketamine nasal spray is a separate product (outside this page)
Dosing & Administration
The house doses below come from NASEMSO 2022 and the cited trials. Local protocol may differ.
Available Forms
- 10 mg/mL: 200 mg in 20 mL multiple-dose vial; isotonic; IV without dilution, for small titrated doses
- 50 mg/mL: 500 mg in 10 mL multiple-dose vial; IV without dilution or IM
- 100 mg/mL: 500 mg in 5 mL multiple-dose vial; IM or IN without dilution; must be diluted with an equal volume of sterile water, NS or D5W before IV use
- EMS / transport: most services stock the 50 or 100 mg/mL vial (agency-specific)
High-Alert Medication: Three strengths in similar vials make mg-to-mL errors easy, and those errors run 2- to 10-fold. Analgesic and anesthetic doses can differ by up to 50-fold (0.1 mg/kg vs 5 mg/kg). Independently double-check concentration, mg, mg/kg, weight and volume before every IM, bolus and infusion.
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| RSI / induction | 1–2 mg/kg IV/IO over 30–60 sec | Single dose; usual max 2 mg/kg for RSI (label range 1–4.5 mg/kg) | High-alert Actual body weight in most adults (2025 RSI trial median 1.6 mg/kg); obesity: see Special Populations. In shock, many use about 1 mg/kg after resuscitation. Start post-intubation analgosedation. |
| Procedural sedation, IV | 1 mg/kg IV over 30–60 sec; then 0.5–1 mg/kg IV as needed | No fixed max: titrate to dissociation; larger totals prolong recovery | High-alert Rapid push causes apnea and a pressor surge. Optional midazolam 0.03 mg/kg IV reduces adult recovery reactions; ondansetron reduces vomiting. |
| Procedural sedation, IM | 4–5 mg/kg IM | Repeat once (half to full dose) if inadequate after 5–10 min | High-alert Slower onset, longer recovery, more vomiting than IV. |
| Acute pain, sub-dissociative IV/IO/IM | 0.25 mg/kg (range 0.1–0.25 mg/kg) IV/IO/IM; IV over 10–15 min in 50–100 mL NS or slow push | Max initial 25 mg; cumulative max 100 mg; repeat after 5 min only if pain persists and the patient stays conversant | High-alert Slower delivery reduces dysphoria. Differs from ASRA/AAPM/ASA 2018: bolus up to 0.35 mg/kg; the field cap is 25 mg initial. |
| Acute pain, IN | 0.75 mg/kg IN (100 mg/mL by atomizer, split between nares); 0.5 mg/kg in older or frail adults | Single IN dose max 100 mg (house-derived; no guideline sets an IN mg cap); max 1 mL per naris; no repeat IN dose in the field | High-alert For patients without IV access. Adult dose studied prehospital in PAIN-K 2019. |
| Severe agitation (hyperactive delirium) | 3–5 mg/kg IM, or 1 mg/kg IV; use the low end of the range | Max 5 mg/kg IM per dose; repeat only with medical direction. No guideline absolute mg cap: the agency or medical director sets one | High-alert Weight estimates are often wrong (see Clinical Pearls). Continuous SpO₂, EtCO₂ and ECG; airway equipment ready. |
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Procedural sedation, IV | 1.5–2 mg/kg IV/IO over 30–60 sec; then 0.5–1 mg/kg IV as needed | Single 2 mg/kg (not above the adult dose); total titrated to effect | High-alert Airway events rise with an initial dose ≥2.5 mg/kg or total ≥5 mg/kg. No routine anticholinergic or benzodiazepine. |
| Procedural sedation, IM | 4–5 mg/kg IM | Repeat once (half to full dose) if inadequate after 5–10 min | High-alert No IV needed; more vomiting than IV. |
| RSI / induction | 1–2 mg/kg IV/IO | Single dose; max 2 mg/kg (not above the adult dose) | High-alert Use measured or length-based weight (Broselow). |
| Acute pain, sub-dissociative IV/IO/IM | 0.1–0.25 mg/kg IV/IO/IM; IV slowly over 10–15 min | Max initial 25 mg; cumulative max 100 mg (NASEMSO 2022, all ages) | High-alert Monitor SpO₂. |
| Acute pain, IN | 1–1.5 mg/kg IN (1.5 mg/kg is the PRIME trial dose, ages 8–17) | Max 1.5 mg/kg per dose; max 1 mL per naris; single-dose cap 100 mg (house-derived, same as adult) | High-alert Noninferior to IN fentanyl for limb injuries (age 8–17 yr; PRIME 2019); more minor side effects. |
| Severe agitation | Not established in children: online medical direction or specialist use only | — | Treat hypoglycemia, hypoxia and hyperthermia first. |
| Infants <6 months | Ketamine sedation contraindicated <3 months per ACEP 2011; current multidisciplinary guidance generally avoids procedural sedation <6 months (airway and respiratory risk); anesthesia use is specialist only | — | See weight-based dosing. |
Continuous Infusion
| Setting | Example Concentration | Start | Titrate | Usual Range / Max |
|---|---|---|---|---|
| ED / ward analgesia (adult) | 1 mg/mL (example, institution-specific) | 0.1 mg/kg/hr, with or without a bolus of up to 0.25 mg/kg (max 25 mg initial; see the IV pain row) | To pain score and side effects per protocol | 0.1–0.5 mg/kg/hr; max 1 mg/kg/hr without intensive monitoring |
| Postsurgical ICU adults, opioid-sparing adjunct (PADIS 2018 conditional suggestion, very low-quality evidence) | 1 mg/mL (example, institution-specific) | 0.5 mg/kg IV once, then 0.06 mg/kg/hr | Up to 0.12 mg/kg/hr to pain score | 0.06–0.12 mg/kg/hr (equal to 1–2 mcg/kg/min) |
| ICU analgosedation, ventilated adult | 1–2 mg/mL (example, institution-specific) | Per institutional protocol | To RASS goal and pain score | No guideline range; institutional protocol only |
Preparation & Administration
- Dilution: dilute 100 mg/mL 1:1 before IV. Infusion: 500 mg in 500 mL NS or D5W (1 mg/mL), or in 250 mL (2 mg/mL) if fluid-restricted; use immediately.
- Push rate: induction and sedation doses over 30–60 sec (label: 60 sec); analgesic doses over 10–15 min.
- IM / IN / IO: IM into a large muscle, splitting large volumes; IN by atomizer, max 1 mL per naris; IO same dose as IV.
- Antisialagogue: No routine anticholinergic. ACEP 2026 multidisciplinary sedation guidance links co-given anticholinergics to more adverse events. The FDA label differs: it advises one before induction. Keep suction ready.
- Pump: smart pump with a drug library.
Dosing Notes: Don't delay urgent sedation for fasting time alone. ACEP 2026 says so. The FDA label differs: it discourages use in patients who haven't fasted. Renal and hepatic details sit under Special Populations.
Contraindications & Precautions
Contraindications
- Significant blood pressure rise would be a serious hazard (FDA label): e.g., aortic dissection, hypertensive emergency, active myocardial ischemia
- Known hypersensitivity to ketamine or any excipient
- For ED procedural sedation: age <3 months and known or suspected schizophrenia (ketamine-specific ACEP guideline; not label contraindications). Current multidisciplinary guidance generally avoids procedural sedation under 6 months.
- No absolute bar exists when ketamine is the safest option for a life-threatening airway or agitation emergency
Precautions
- Catecholamine-depleted shock: Direct myocardial depression can cause hypotension. Resuscitate first, then reduce the dose.
- Cardiovascular disease (relative): the sympathomimetic surge pushes myocardial oxygen demand up.
- Airway procedures: The reflexes stay intact. Avoid it as the sole agent when the posterior pharynx is stimulated. An active URI or asthma in children raises laryngospasm risk.
- Raised ICP or head injury: A precaution, not a contraindication, per ACEP 2011. Keep ventilation controlled and avoid hypoventilation. The FDA label differs: it reports ICP increases.
- Relative: glaucoma or open globe, psychosis, porphyria, thyroid disease or thyroid hormone therapy.
- Analgesic infusions (ASRA/AAPM/ASA 2018): avoid in pregnancy, active psychosis, poorly controlled cardiovascular disease, and elevated ICP or intraocular pressure.
- Recurrent dosing: liver and urological injury (see Monitoring).
Hold / Reassess If
- SpO₂ <90%, EtCO₂ up >10 mmHg from baseline, or a flat capnogram: stop, reposition, ventilate
- MAP <65 mmHg after a dose: resuscitate, vasopressor, no further bolus
- SBP >180 mmHg with chest pain, ischemic ECG changes or neurologic signs: stop and treat
Not a custody tool: EMS must never sedate a person to make an arrest easier or to help law enforcement take them into custody. Sedate only to protect the patient and others, or to allow treatment. Then monitor and transport.
Adverse Effects & Toxicity
Common
- Emergence reactions (dreams, hallucinations, delirium): about 12% after anesthesia; more in adults
- Transient hypertension and tachycardia: BP peaks 10–50% above baseline, settles by about 15 min
- Vomiting: usually in recovery; more in adolescents and after IM
- Hypersalivation and lacrimation
- Nystagmus, hypertonicity, purposeless movements: expected
- Sub-dissociative doses: dizziness, dysphoria, feelings of unreality, nausea
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Laryngospasm | Stridor or silent chest despite effort, flat capnogram, falling SpO₂ | Jaw thrust, suction, BVM with 100% O₂ and PEEP; if it persists, paralyze (succinylcholine or rocuronium) and intubate |
| Apnea / hypoventilation | After rapid push, high doses or co-sedatives; rising EtCO₂, falling RR and SpO₂ | Airway maneuvers and BVM; usually brief. Slow future pushes |
| Hypotension / cardiovascular collapse | Catecholamine-depleted shock; falling MAP, bradycardia, arrest | Fluids or blood, norepinephrine or push-dose pressor, lower doses; ACLS if arrest |
| Hypertensive crisis / ischemia | Chest pain, ischemic ECG changes, neurologic signs | Stop dosing; benzodiazepine; treat ischemia |
| Severe emergence delirium | Thrashing, distressing hallucinations in recovery | Quiet, dim environment; small IV dose of midazolam |
| Hepatobiliary and urological injury | Repeated use: cholestatic LFTs; cystitis, hematuria, hydronephrosis | Stop ketamine; refer to hepatology or urology |
| Anaphylaxis (rare) | Urticaria, bronchospasm, hypotension | Stop; epinephrine IM and anaphylaxis care |
Overdose & Toxicity Management
- Signs: Look for deep dissociation, apnea and swings in BP and HR. Recreational use adds agitation and psychosis.
- Management: Support the airway and ventilate. Overdoses up to 10 times the usual dose have recovered fully, though slowly.
- No antidote: naloxone helps only if opioids were co-ingested. Use benzodiazepines for severe agitation. Extracorporeal removal has no role.
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical: SpO₂ | Continuous from first dose until recovery | <90%: reposition, O₂, assist ventilation |
| Clinical: waveform EtCO₂ | Continuous for every sedation, agitation and induction dose | Rise >10 mmHg from baseline, EtCO₂ >50 mmHg or flat line: airway maneuvers, ventilate |
| Clinical: ECG and HR | Continuous | New dysrhythmia or ischemic changes: no further doses, treat |
| Clinical: BP | Baseline, then every 5 min during sedation or agitation care; per protocol on infusions | MAP <65 mmHg: resuscitate; SBP >180 mmHg with symptoms: stop and treat |
| Clinical: sedation score (RASS) | Before and after each dose; every 5–15 min until stable | Document; RASS -4 to -5 needs constant airway attention |
| Clinical: airway and secretions | Dedicated monitor (not the proceduralist) | Suction, reposition; never leave the patient alone |
| Clinical: recovery | Until baseline speech, awareness and purposeful movement | Do not discharge earlier; watch for emergence reactions. No driving, hazardous machinery or activities for 24 hr after discharge (label) |
| Laboratory: agitation workup | On arrival for hyperactive delirium | |
| Laboratory: LFTs with recurrent dosing | Baseline and periodically (label) | |
| Infusion safety | Every titration, at least every 2 hr, and at handoff | Confirm concentration and mg/kg/hr; reassess pain, RASS, dysphoria |
Interactions & Compatibility
Clinically Significant Interactions
| Drug / Class | Effect | What To Do |
|---|---|---|
| Opioids, benzodiazepines, alcohol, other CNS depressants | Profound sedation, respiratory depression, coma; opioids prolong recovery | Lower doses; continuous SpO₂ and EtCO₂; avoid stacking weight-based opioids with ketamine for analgesia |
| Theophylline, aminophylline | Lower seizure threshold | Label Highlights: do not co-administer (full prescribing information: consider an alternative). Use another induction or sedation agent where possible |
| Sympathomimetics, vasopressin | Enhanced tachycardia and hypertension (label) | Monitor HR and BP closely; individualize the dose |
| Strong CYP3A4 / CYP2B6 inhibitors or inducers (e.g., clarithromycin, ritonavir; rifampin) | Higher or lower ketamine exposure; most relevant with repeated or infusion dosing | Titrate to effect; reassess sedation depth |
| Antipsychotics given for agitation (e.g., droperidol) | Additive sedation; droperidol adds QT risk | ECG monitoring; reassess before redosing either drug |
IV Compatibility
- Diluents: NS or D5W for infusions; sterile water, NS or D5W for the 1:1 dilution of 100 mg/mL.
- Do not mix in the same syringe with barbiturates or diazepam (precipitation).
- Flush the line before and after when sharing a catheter with other sedatives.
- Verify with an institutional compatibility resource.
Special Populations
- Pediatrics: The label says safety below 16 years is not established. Ketamine is still the best-studied ED pediatric sedative (ACEP guideline). Repeated or prolonged (>3 hr) anesthetic exposure at <3 years carries an FDA neurotoxicity warning. Doses are in the Pediatric Dosing table. For PICU analgosedation, a 2026 meta-analysis found only low or very low certainty evidence and no recommended dose range. Dosing follows PICU protocol.
- Neonates: Sedation is contraindicated under 3 months (ketamine-specific ACEP guideline, 2011). It is generally avoided under 6 months because of airway obstruction, laryngospasm and apnea. Anesthesia use stays with specialists.
- Pregnancy: Most of the data come from cesarean deliveries, and they show no drug-associated risk. Animal studies show neuroapoptosis after prolonged late-gestation exposure, which is why the FDA neurotoxicity caution also covers prolonged or repeated third-trimester exposure. ASRA/AAPM/ASA advise against ketamine infusions for acute pain in pregnancy. Never hold back an indicated emergency anesthetic or airway dose.
- Lactation: Ketamine gets into milk. The label limits lactating women to anesthesia. ACEP 2026, citing 2020 anaesthesia breastfeeding guidelines, supports normal breastfeeding once the mother has recovered. Watch the infant for sedation, breathing problems and increased tone. Take extra care at 6 weeks or younger.
- Older Adults: Start at the low end. The risk of hypertension, ischemia and emergence delirium is higher. It is not listed in the 2023 AGS Beers Criteria.
- Renal Impairment: No specific adjustment is established. Clearance is hepatic.
- Hepatic Impairment: Avoid analgesic infusions in severe dysfunction (e.g., cirrhosis). Use caution in moderate disease.
- Obesity / Dosing Weight: No obesity dosing has been validated. For procedural sedation and analgesia, base most doses on ideal body weight and titrate (ACEP 2026 sedation guidance). For RSI, no validated obesity weight exists, and protocols vary between actual, adjusted and ideal body weight.
- Opioid-Tolerant Patients: Sub-dissociative ketamine is a useful adjunct that spares opioids.
Field & Transport Considerations
- Scope: Paramedic and critical-care transport use it for RSI, sedation, IM agitation and analgesia. Scope varies by state and agency protocol.
- Storage & Stability: Keep it at 20–25 °C (68–77 °F). Excursions of 15–30 °C (59–86 °F) are the outer limit. Protect it from light. Schedule III means secure storage, a count and a witnessed waste.
- Carried Concentration: Know whether the vial is 50 or 100 mg/mL. Say the dose in mg and mL at the cross-check. Dilute 100 mg/mL before IV use.
- Agitation Calls: Start with verbal de-escalation. No prone or hobble restraint, and nothing over the neck or chest. Once sedated, watch SpO₂, EtCO₂ and ECG continuously. Document a RASS score before and after. Every sedated patient goes to an ED.
- Infusions in Transport: A smart pump with a drug library. Verify concentration and mg/kg/hr at handoff. Carry enough volume for the trip plus delays.
- Altitude / Environment: Aircraft and ambulance noise, light and rough handling can worsen emergence reactions. Keep stimulation to a minimum.
- Handoff Essentials: time, dose in mg and mg/kg, route, estimated vs measured weight, response (RASS), airway events, other sedatives given, current infusion rate and last titration.
Clinical Pearls
The weight estimate is the dose: Say a 5 mg/kg IM dose is calculated for an estimated 100 kg patient who actually weighs 70 kg. That lands at about 7 mg/kg, an anesthetic dose. Estimate conservatively, use the low end or the agency's fixed dose, and be ready to manage the airway.
Ketamine vs etomidate in critically ill adults (FP-C, CCRN): The 2025 RSI trial enrolled 2,365 adults. 28-day mortality was about the same (28.1% vs 29.1%). Cardiovascular collapse was more frequent with ketamine (22.1% vs 17.0%), and most of that sat in sepsis (30.6% vs 20.9%) and APACHE II ≥20 (31.4% vs 20.7%). Resuscitate before induction.
Spot laryngospasm on the capnogram: The chest moves, but there's no EtCO₂ waveform. Stridor or silence means laryngospasm, not apnea. Start with jaw thrust and positive pressure. Paralysis if it won't break.
Dissociation looks alarming: Open eyes, nystagmus, hypertonicity and random limb movements are expected with dissociation. They don't mean the sedation is too light. Don't redose for them. Brief family and team first.
Induction wears off before the paralytic: An RSI dose lasts 5–10 minutes. Rocuronium lasts far longer. So start analgosedation as soon as the tube is confirmed, so the patient doesn't wake up aware and paralyzed.
Terminology (NREMT, CEN): ACEP (2023) and ACMT have dropped "excited delirium". Document it as hyperactive delirium with severe agitation, and treat it as a medical emergency. Check glucose, temperature and potassium.
Pharmacology
Mechanism of Action
- Noncompetitive NMDA receptor antagonist (phencyclidine site). It blocks glutamate signaling, which produces dissociative anesthesia, amnesia and analgesia, and less central sensitization.
- Inhibits catecholamine reuptake: heart rate, BP and cardiac output go up. Direct negative inotropy shows up once catecholamine stores are depleted.
- Bronchodilation: it suits patients at high risk of bronchospasm.
- Respiratory drive and airway reflexes largely preserved at dissociative doses. Reflexes still don't reliably prevent aspiration.
- Norketamine, the main active metabolite, is about one-third as potent as ketamine.
Pharmacokinetics
| Route | Onset | Peak | Duration |
|---|---|---|---|
| IV | 30 sec | About 1 min | 5–10 min (dissociation) |
| IM | 3–4 min (label, 9–13 mg/kg) | About 5 min | 12–25 min (anesthetic effect, label); full recovery takes longer |
| IN | 10–15 min | — | 30–60 min (analgesia) |
- Half-life: The distribution phase lasts 10–15 min and matches the anesthetic effect. The elimination phase is about 2.5 hr. Norketamine builds up with prolonged infusions.
- Metabolism: The liver does N-demethylation by CYP2B6 and CYP3A4 to norketamine, then hydroxylation and glucuronidation.
- Elimination: Conjugated metabolites leave in the urine.
- Bioavailability: IM is about 90%, and IN about 45–50%.
Names & Classification
- Generic Name
- Ketamine hydrochloride (strengths expressed as ketamine base)
- Brand Names
- Ketalar; multiple generics. Esketamine (Spravato) is a separate S-enantiomer nasal spray for depression and is not interchangeable.
- Pharmacologic Class
- NMDA receptor antagonist (arylcyclohexylamine, phencyclidine derivative)
- Therapeutic Class
- Dissociative general anesthetic; analgesic; sedative
- Controlled Substance
- C-III (DEA Schedule III)
- ISMP High-Alert
- Yes: ISMP high-alert medication (general anesthetic agents, IV)
- Look-Alike / Sound-Alike
- No name pair commonly reported; the main error is concentration confusion between 10, 50 and 100 mg/mL vials, and ketamine vs esketamine
References
- Par Health. (2026). KETALAR (ketamine hydrochloride) injection, CIII: Full prescribing information (revised 03/2026). U.S. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/016812s057lbl.pdf
- American College of Emergency Physicians Clinical Policies Subcommittee on Severe Agitation; Thiessen, M. E. W., Godwin, S. A., Hatten, B. W., Whittle, J. A., Haukoos, J. S., & Diercks, D. B. (2024). Clinical policy: Critical issues in the evaluation and management of adult out-of-hospital or emergency department patients presenting with severe agitation. Annals of Emergency Medicine, 83(1), e1–e30. https://doi.org/10.1016/j.annemergmed.2023.09.010
- Kupas, D. F., Wydro, G. C., Tan, D. K., Kamin, R., Harrell, A. J., IV, & Wang, A. (2021). Clinical care and restraint of agitated or combative patients by emergency medical services practitioners (NAEMSP, NASEMSO, NEMSMA, NAEMT and APA joint position statement). Prehospital Emergency Care, 25(5), 721–723. https://pubmed.ncbi.nlm.nih.gov/33877949/
- Casey, J. D., Seitz, K. P., Driver, B. E., Gibbs, K. W., Ginde, A. A., Trent, S. A., Russell, D. W., et al., for the RSI Investigators and the Pragmatic Critical Care Research Group. (2026). Ketamine or etomidate for tracheal intubation of critically ill adults. New England Journal of Medicine, 394(16), 1608–1620 (published online December 2025). https://pmc.ncbi.nlm.nih.gov/articles/PMC12711137/
- Schwenk, E. S., Viscusi, E. R., Buvanendran, A., Hurley, R. W., Wasan, A. D., Narouze, S., Bhatia, A., Davis, F. N., Hooten, W. M., & Cohen, S. P. (2018). Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine, 43(5), 456–466. https://pmc.ncbi.nlm.nih.gov/articles/PMC6023582/
- Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., et al. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU (PADIS). Critical Care Medicine, 46(9), e825–e873. https://doi.org/10.1097/CCM.0000000000003299
- Green, S. M., Roback, M. G., Kennedy, R. M., & Krauss, B. (2011). Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update (landmark guideline; adult and pediatric). Annals of Emergency Medicine, 57(5), 449–461. https://doi.org/10.1016/j.annemergmed.2010.11.030
- American College of Emergency Physicians; Green, S. M., Roback, M. G., Bhatt, M., Andolfatto, G., Caperell, K., et al. (2026). Unscheduled procedural sedation: Multidisciplinary Delphi consensus guidelines, part 2: Clinical practice (ACEP policy statement). Annals of Emergency Medicine, 88(3), 346–361. https://doi.org/10.1016/j.annemergmed.2026.06.039
- National Association of State EMS Officials. (2022, March). National Model EMS Clinical Guidelines, Version 3.0: Pain Management (pp. 93–94). NASEMSO. https://hhs.iowa.gov/media/198/download
- Andolfatto, G., Innes, K., Dick, W., Jenneson, S., Willman, E., Stenstrom, R., Zed, P. J., & Benoit, G. (2019). Prehospital analgesia with intranasal ketamine (PAIN-K): A randomized double-blind trial in adults. Annals of Emergency Medicine, 74(2), 241–250. https://doi.org/10.1016/j.annemergmed.2019.01.048
- Frey, T. M., Florin, T. A., Caruso, M., Zhang, N., Zhang, Y., & Mittiga, M. R. (2019). Effect of intranasal ketamine vs fentanyl on pain reduction for extremity injuries in children: The PRIME randomized clinical trial. JAMA Pediatrics, 173(2), 140–146. https://doi.org/10.1001/jamapediatrics.2018.4582
- Zorko, D. J., Zou, D., Sharif, S., Dearness, K., Rochwerg, B., & Parker, M. J. (2026). Ketamine for analgosedation in critically ill mechanically ventilated children: A systematic review and meta-analysis. Critical Care Explorations, 8(5), e1408. https://doi.org/10.1097/CCE.0000000000001408
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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