Is There a Role for Intravenous Subdissociative-Dose Ketamine Administered as an Adjunct to Opioids or as a Single Agent for Acute Pain Management in the Emergency Department?

Published:September 29, 2016DOI:



      Whether acute or chronic, emergency physicians frequently encounter patients reporting pain. It is the responsibility of the emergency physician to assess and evaluate, and if appropriate, safely and effectively reduce pain. Recently, analgesics other than opioids are being considered in an effort to provide safe alternatives for pain management in the emergency department (ED). Opioids have significant adverse effects such as respiratory depression, hypotension, and sedation, to say nothing of their potential for abuse. Although ketamine has long been used in the ED for procedural sedation and rapid sequence intubation, it is used infrequently for analgesia. Recent evidence suggests that ketamine use in subdissociative doses proves to be effective for pain control and serves as a feasible alternative to traditional opioids. This paper evaluates ketamine's analgesic effectiveness and safety in the ED.


      This is a literature review of randomized controlled trials, systematic reviews, meta-analyses, and observational studies evaluating ketamine for pain control in the ED setting. Based on these search parameters, eight studies were included in the final analysis and graded based on the American Academy of Emergency Medicine Clinical Practice Committee manuscript review process.


      A total of eight papers were reviewed in detail and graded. Recommendations were given based upon this review process.


      Subdissociative-dose ketamine (low-dose ketamine) is effective and safe to use alone or in combination with opioid analgesics for the treatment of acute pain in the ED. Its use is associated with higher rates of minor, but well-tolerated adverse side effects.


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        • Cordell W.H.
        • Keene K.K.
        • Giles B.K.
        • Jones J.B.
        • Jones J.H.
        • Brizendine E.J.
        The high prevalence of pain in emergency medical care.
        Am J Emerg Med. 2002; 20: 165-169
        • Paqueron X.
        • Lumbroso A.
        • Mergoni P.
        • et al.
        Is morphine-induced sedation synonymous with analgesia during intravenous morphine titration?.
        Br J Anaesth. 2002; 89: 697-701
        • Bijur P.E.
        • Kenny M.K.
        • Gallagher E.J.
        Intravenous morphine at 0.1mg/kg is not effective for controlling acute pain in the majority of patients.
        Ann Emerg Med. 2005; 46: 362-365
        • Dickenson A.H.
        NMDA receptor antagonists: interactions with opioids.
        Acta Anaesthesiol Scand. 1997; 41: 112-115
        • Johansson P.
        • Kongstad P.
        • Johansson A.
        The effect of combined treatment with morphine sulphate and low-dose ketamine in a prehospital setting.
        Scand J Trauma Resusc Emerg Med. 2009; 17: 61
        • Jennings P.A.
        • Cameron P.
        • Bernard S.
        • et al.
        Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial.
        Ann Emerg Med. 2012; 59: 497-503
        • Jennings P.A.
        • Cameron P.
        • Bernard S.
        Ketamine as an analgesic in the pre-hospital setting: a systematic review.
        Acta Anaesthesiol Scand. 2011; 55: 638-643
        • Galinski M.
        • Dolveck F.
        • Combes X.
        • et al.
        Management of severe acute pain in emergency settings: ketamine reduces morphine consumption.
        Am J Emerg Med. 2007; 25: 385-390
        • Ahern T.L.
        • Herring A.A.
        • Stone M.B.
        • Frazee B.W.
        Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain.
        Am J Emerg Med. 2013; 31: 847-851
        • Beaudoin F.L.
        • Lin C.
        • Guan W.
        • Merchant R.C.
        Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.
        Acad Emerg Med. 2014; 21: 1193-1202
        • Miller J.P.
        • Schauer S.G.
        • Ganem V.J.
        • Bebarta V.S.
        Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial.
        Am J Emerg Med. 2015; 33: 402-408
        • Motov S.
        • Rockoff B.
        • Cohen V.
        • et al.
        Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial.
        Ann Emerg Med. 2015; 66: 222-229
        • Weinbroum A.A.
        A single small dose of postoperative ketamine provides rapid and sustained improvement in morphine analgesia in the presence of morphine-resistant pain.
        Anesth Analg. 2003; 96: 789-795