Medically facilitated intubation or MFI?
Check out this excellent Prezi presentation by EM resident Janet Ferguson of Saskatchewan. It has lots of concepts and images from FOAMEd community, like DSI, Rocketamine , NODESAT(Apneic Oxygenation)!
I wanted to highlight an issue brought up in the presentation. It is listed that SCHIZOPHRENIA IS AN ABSOLUTE CONTRAINDICATION TO KETAMINE.
This is a medical myth. Like many myths it was borne out of some truth but like a lot of things in medicine and life, the truth gets distorted. Bit like ketamine and head injuries!
Early research in patients with schizophrenia and followup studies clearly show that ketamine in subanaesthetic doses , produces increase in positive symptoms of schizophrenia ( hallucinations mainly) TRANSIENTLY.
Several case reports and series from the psychiatric and anaesthetic literature have challenged this notion that ketamine worsens schizophrenia course.
Preliminary evaluation of clinical outcome and safety of ketamine as an anesthetic for electroconvulsive therapy in schizophrenia.
Moreover my aeromedical retrieval work in the last 6 years has found many cases of patients with schizophrenia in which I have used ketamine sedation in a wide dosing range ( 0.5mg/kg – 1.5mg/kg) with excellent results and my communication with our local psychiatrists has been positive in this regard. And remember IV ketamine is not long lasting. It has a temporary effect so any increase in hallucinations/delirium is not going to last weeks or months. This is well described in psychopharmacologic literature.
The KEY to minimising /avoiding ketamine induced hallucinations/delirium/thought disorder in patients with schizophrenia in particular is to ALWAYS USE IT AS A SECOND LINE SEDATIVE . USE ADJUNCTIVE SEDATION WITH YOUR KETAMINE! I use droperidol and midazolam. Others have used propofol.
Dr Friedberg, an American Anaesthesiologist describes this as “Hypnosis First, then Dissociation“. He has been using a propofol then ketamine sedation technique for cosmetic day surgery for many years with success
IN this Japanese study..
In this study, postoperative confusion occurred in 5 (14%) of schizophrenic patients (Group A) with small-dose ketamine and in 8 (23%) of schizophrenic patients (Group B) without ketamine. Hallucinations occurred in 1 (3%) of Group A and in 2 (6%). There was no significant difference in incidence of postoperative hallucinations between Groups A and B.
(taken from this published letter by Chief investigator Dr Kudoh)
So consider that the absolute contraindication of ketamine to patients with schizophrenia is indeed a medical myth. It is a RELATIVE CONTRAINDICATION NOT ABSOLUTE.
In emergency medicine in particular, my friend Casey Parker of BroomeDocs put it best I thought
I would rather have a patient be alive and a bit crazier than..be dead.