Table 1.

Ketamine treatment protocols.

	Subdissociative-dose ketamine (SDDK) for analgesia	Ketamine for severe agitation/excited delirium
Indications	First-line analgesic therapy for management of severe pain in the following scenarios: Acute pain secondary to traumatic injury Acute pain in patients with documented allergy/intolerance to parenteral opioid therapy Chronic pain in patients who are not candidates for opioid or NSAID therapy Adjunct analgesic therapy for the management of severe pain in ED patients who failed to achieve therapeutic response with parenteral opioid therapy	First-line pharmacologic monotherapy for adult patients with severe agitation, excited delirium, and violent/self-destructive behavior who meet the following criteria: Patient poses an immediate threat to patient and healthcare provider safety (RASS score of +4) Failure and/or futility of alternative non-pharmacologic de-escalation strategies Absence of IV access Not a candidate for intramuscular antipsychotics and/or benzodiazepines due to unacceptably protracted onset of action
Contraindications	Unstable vital signs Systolic blood pressure > 180 mmHg Heart rate > 150 beats per minute Respiratory rate < 10 or > 30 Suspected acute coronary syndrome Acute decompensated heart failure Unstable dysrhythmia Acute head or ocular trauma Suspected elevated intracranial pressure History of schizophrenia or other psychosis Active psychosis	None
Dosing regimen and administration	0.2 – 0.3 mg/kg (up to a max dose of 25 mg) Administered as slow IV push over 5 minutes Dose may be repeated once in 30 minutes	4 mg/kg IM up to max single dose of 500 mg Dosing weight can be estimated if actual weight unavailable Immediate availability of advanced airway equipment
Patient monitoring	Vital signs (including pain assessment) at baseline, 15 minutes, and 30 minutes after each dose followed by routine nursing care per department protocol Continuous pulse oximetry for at least 30 minutes after dose administration Telemetry for at least 30 minutes after dose administration Immediate availability of ED attending physician for at least 30 minutes	Continuous direct patient observation for minimum of 15 minutes Continuous pulse oximetry, cardiac monitor, and end-tidal CO2 monitoring (if available) Removal of physical restraints Supine patient positioning with elevation of head of bed at 30°

ED, emergency department; NSAID, Nonsteroidal anti-inflammatory drugs; RASS, Richmond Agitation-Sedation Scale; IV, intravenous; mmHg, millimeters of mercury; mg/kg, milligrams per kilogram; CO₂, carbon dioxide.