Low-dose ketamine in the prehospital setting.

We read the recent CMAJ article on ketamine for the treatment of acute pain by Silverstein and colleagues with great interest.1 They note that low-dose ketamine is an effective analgesic in several clinical settings, including anesthesiology, critical care, pain management and emergency medicine.2

We wish to bring attention to emerging literature that effective and safe administration of low-dose ketamine can be provided to adult and pediatric patients by paramedics in the prehospital setting.3 Importantly, a joint position statement supporting the prehospital use of ketamine as an analgesic in acute trauma patients has recently been published by several American organizations, including the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians and the National Association of Emergency Medical Services Physicians.4

Given the limitations of opioids, nonopioid analgesia is clearly needed in the prehospital environment. Examples include high-acuity trauma patients at risk for (or exhibiting) hemorrhagic shock or respiratory compromise, patients in severe pain with known allergies to morphine and fentanyl, and patients with a history of narcotic use disorder who do not wish to be administered opioids or who are receiving treatment with buprenorphine–naloxone.

Medical directives for ketamine analgesia are already in place for paramedic use in several Canadian provinces, and Ontario is in the process of doing likewise. We applaud this recent addition to the paramedic scope of practice for the management of severe pain.