Ketamine for Acute Pain in the ED: Mechanisms, Protocols, and Safety Considerations
https://doi.org/10.22034/thr.2025.237240
Hossein Meskar, Ramin Razavi, Ali Zarei, Goli Aezzi Pashakollaei, Mostafa Jamali Jehizdani, Keihan Shabankhani
Abstract Background: Acute pain is one of the most frequent presenting complaints in emergency departments (EDs). In the context of the global opioid crisis, there is increasing interest in effective non-opioid and opioid-sparing analgesic strategies. Ketamine, at subanesthetic doses, has emerged as a valuable option for acute pain management due to its unique pharmacologic profile.
Objectives: This narrative review aims to synthesize current evidence on the mechanisms of analgesia, clinical efficacy, dosing protocols, and safety considerations of ketamine for acute pain management in adult ED patients.
Methods: A comprehensive narrative review of the literature was conducted using recent randomized controlled trials, systematic reviews, meta-analyses, and international guidelines focusing on ketamine use for acute pain in emergency settings. Studies from diverse geographic regions and healthcare systems were included to provide a global perspective.
Results: Evidence consistently demonstrates that subdissociative-dose ketamine provides analgesia comparable to opioids for acute pain in the ED. Typical intravenous doses of 0.1–0.35 mg/kg, administered as a bolus or infusion, achieve rapid pain relief while preserving respiratory drive and airway reflexes. Ketamine is associated with higher rates of transient neuropsychiatric effects, such as dizziness and emergence reactions, but lower risks of respiratory depression compared with opioids. Alternative routes of administration, including intranasal and subcutaneous, offer additional flexibility in selected patients.
Conclusion: Ketamine is a safe and effective alternative or adjunct to opioids for acute pain management in the emergency department when used at appropriate subanesthetic doses. With proper patient selection, monitoring, and adherence to established protocols, ketamine can play a central role in multimodal ED analgesia strategies aimed at improving pain control while reducing opioid exposure.
Effect of Inhaled Salbutamol on Pain Severity in Patients Presenting with Acute Renal Colic: A Double-Blind Randomized Clinical Trial
https://doi.org/10.22034/thr.2025.531758.1016
Seyed Mohammad Hosseininejad, Iraj Goli Khatir, Hoseinali Khodadadi
Abstract Background: Renal colic is a common and severely painful emergency condition often caused by ureteral stones. Rapid pain management is critical. This study evaluates the efficacy of inhaled salbutamol, a β2-agonist with smooth muscle relaxant properties, as an adjunct therapy in reducing pain severity in patients with acute renal colic.
Methods: In this double-blind randomized controlled trial, 204 patients with moderate renal colic pain (based on the Visual Analog Scale, VAS) referred to the emergency department of Imam Khomeini Hospital in Sari, Iran, were randomly assigned to two groups. The intervention group received 30 mg intravenous ketorolac and inhaled salbutamol (5 puffs), while the control group received ketorolac and a placebo inhalation. Pain intensity, vital signs, and symptoms such as nausea and vomiting were recorded at baseline and at intervals of 10, 20, 30, 45, 60, and 120 minutes after treatment.
Results: Pain intensity significantly decreased over time in both groups (p